Clinical pathway development to standardize pharmacological medication management of agitation in pediatric inpatient settings.

Objective: Acute agitation in pediatrics is commonly encountered in hospital settings, can contribute to significant physical and psychological distress, and management is highly varied in practice. As such, the development of a standardized pharmacologic guideline is paramount. We aimed to develop a novel clinical pathway (CP) for management of acute agitation for all hospitalized pediatric patients in Canada. Methods: Healthcare professionals in Canada with expertise in treating and managing pediatric agitation formed a working group and developed a CP through conducting a literature review, engaging key partners, and obtaining interdisciplinary consensus (iterative real-time discussions with content experts). Once developed, the preliminary CP was presented to additional internal and external partners via multiple grand rounds and a webinar; feedback from participants guided final CP revisions. Results: The working group created a pediatric inpatient CP to guide pharmacologic management of agitation and serve as an easy-to-use clinical and educational resource with three complementary sections including: 1) a treatment algorithm, 2) a quick reference medication chart, and 3) two supporting documents, which provide a general overview of non-pharmacologic strategies prior to CP implementation and an illustrative scenario to accompany the medication chart to ensure effective utilization. Conclusions: This is the first CP to standardize pharmacological treatment and management of acute agitation in children in inpatient settings in Canada. Although further research is warranted to assess implementation and support process improvement, the CP can be adapted by individual institutions to assist in prompt pharmacological management of pediatric agitation to potentially improve outcomes for patients, families, and healthcare professionals.

Objectif: L'agitation aiguë en pédiatrie survient couramment en milieu hospitalier, elle peut contribuer à une détresse physique et psychologique significative, et la prise en charge en est très variée dans la pratique. Ainsi, l'élaboration de lignes directrices pharmacologiques standardisées est essentielle. Nous cherchions à développer un nouveau parcours clinique (PC) de la prise en charge de l'agitation aiguë pour tous les patients pédiatriques hospitalisés au Canada. Méthodes: Les professionnels de la santé au Canada qui ont l'expertise du traitement et de la prise en charge de l'agitation pédiatrique ont formé un groupe de travail et développé un PC en menant une revue littéraire, en embauchant des partenaires cibles, et en obtenant un consensus interdisciplinaire (discussions itératives en temps réel avec des experts en contenu). Une fois développé, le PC préliminaire a été présenté à des partenaires internes et externes additionnels lors de multiples grandes rondes et à un webinaire; les commentaires des participants ont guidé les révisions finales du PC. Résultats: Le groupe de travail a créé un PC pour patient psychiatrique hospitalisé afin de guider la prise en charge pharmacologique de l'agitation et de servir de ressource clinique et éducative facile à utiliser munie de trois sections complémentaires notamment : 1) un algorithme de traitement, 2) un tableau des médicaments de référence, et 3) deux documents de soutien, qui offrent un aperçu général de stratégies non-pharmacologiques avant la mise en œuvre du PC et un scénario illustré pour accompagner le tableau des médicaments afin d'assurer une utilisation efficace. Conclusions: C'est le premier PC qui normalise le traitement pharmacologique et la prise en charge de l'agitation aiguë chez les enfants en milieu hospitalier au Canada. Bien que plus de recherche soit justifiée afin d'évaluer la mise en œuvre et de soutenir l'amélioration du processus, le PC peut être adapté par les institutions individuelles afin d'aider à une gestion pharmacologique rapide de l'agitation pédiatrique et de potentiellement aider à la gestion pharmacologique de l'agitation pédiatrique pour les patients, les familles et les professionnels de la santé.

Pediatric Obsessive-Compulsive Disorder Exacerbation and Obstructive Hydrocephalus: A Case Report.

We present the case of an 11 year-old boy with a previous history of obsessive-compulsive disorder (OCD), who experienced a dramatic and acute worsening of OCD symptoms in temporal association with obstructive hydrocephalus secondary to a tectal low-grade glioma. Management and resolution of the hydrocephalus was temporally associated with an improvement in his OCD compulsion symptoms. The present case does not establish proof of cause and effect, but highlights potential multifactorial influences on OCD onset and clinical course. Cortico-striatal-thalamic-cortical pathways, physically distorted by hydrocephalus in this case, have long been implicated in OCD etiology. Clinical implications include the importance of conducting an appropriate neurologic work-up to rule out biological causes for acute and dramatic OCD exacerbations with neurologic signs, even in the context of preexisting OCD. Given that neurologic lesions may exist in the absence of typical signs and symptoms, that they may further disrupt OCD circuitry, and that treatment may lead to resolution of associated psychiatric symptoms, it is important to remain cognizant of these differential diagnoses.

Electronic media use and addiction among youth in psychiatric clinic versus school populations.

OBJECTIVE: Electronic media use is highly prevalent among today's youth, and its overuse in the general population has been consistently associated with the presence of psychiatric symptoms. In contrast, little information exists about electronic media use among youth with psychiatric disorders. Our study aims to compare patterns of television and computer and gaming station use among youth in psychiatric clinic and community-based school populations. METHOD: Surveys were completed by 210 youth and parents, from school (n = 110) and psychiatric clinic (n = 100) populations. Duration and frequency of television, video gaming, and nongaming computer activities were ascertained, along with addictive features of use. Descriptive and comparative analyses were conducted, with a statistical threshold of P < 0.05. RESULTS: Quantitative and qualitative differences were identified between the patterns of use reported by the 2 groups. The mean reported daily duration of exposure to electronic media use was 6.6 hours (SD 4.1) for the clinic sample and 4.6 hours (SD 2.6) for the school sample (P < 0.01). Self-reported rates of addictive patterns related to computer and gaming station use were similar between the 2 populations. However, the clinically based sample favoured more violent games, with 29% reporting playing mature-rated games, compared with 13% reported by the school-based sample (P = 0.02). Youth with externalizing disorders expended greater time video gaming, compared with youth with internalizing disorders (P = 0.01). CONCLUSIONS: Clinically based samples of youth with mental illnesses spend more time engaged in electronic media activities and are more likely to play violent video games, compared with youth in the general population. Further research is needed to determine the long-term implications of these differences.

Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis.

In this case report, the authors present an adverse event possibly caused by miscommunication among three separate medical teams at their hospital. The authors then discuss the hospital's root cause analysis and its proposed solutions, focusing on the subsequent hospital-wide implementation of an automated electronic reminder for abnormal laboratory values that may have helped to prevent similar medical errors.

Computer/gaming station use in youth: Correlations among use, addiction and functional impairment.

OBJECTIVE: Computer/gaming station use is ubiquitous in the lives of youth today. Overuse is a concern, but it remains unclear whether problems arise from addictive patterns of use or simply excessive time spent on use. The goal of the present study was to evaluate computer/gaming station use in youth and to examine the relationship between amounts of use, addictive features of use and functional impairment. METHOD: A total of 110 subjects (11 to 17 years of age) from local schools participated. Time spent on television, video gaming and non-gaming recreational computer activities was measured. Addictive features of computer/gaming station use were ascertained, along with emotional/behavioural functioning. Multiple linear regressions were used to understand how youth functioning varied with time of use and addictive features of use. RESULTS: Mean (± SD) total screen time was 4.5±2.4 h/day. Addictive features of use were consistently correlated with functional impairment across multiple measures and informants, whereas time of use, after controlling for addiction, was not. CONCLUSIONS: Youth are spending many hours each day in front of screens. In the absence of addictive features of computer/gaming station use, time spent is not correlated with problems; however, youth with addictive features of use show evidence of poor emotional/ behavioural functioning.

OBJECTIF: L'utilisation de l'ordinateur et des consoles de jeu est intégrée à la vie des jeunes d'aujourd'hui. La surutilisation demeure une préoccupation, mais on ne sait pas si des problèmes découlent de schèmes d'utilisation dépendants ou simplement d'une durée d'utilisation excessive. La présente étude visait à évaluer l'utilisation de l'ordinateur et des consoles de jeu chez les adolescents ainsi qu'à examiner la relation entre la quantité d'utilisation, les caractéristiques de dépendance et l'atteinte fonctionnelle. MÉTHODOLOGIE: Les chercheurs ont obtenu la participation de 110 sujets de 11 à 17 ans provenant d'écoles locales. Ils ont mesuré le temps consacré à la télévision, aux jeux vidéo et aux activités informatiques récréatives non liées au jeu. Ils ont vérifié les caractéristiques de dépendance d'utilisation de l'ordinateur et de la console de jeu, de même que le fonctionnement affectif et comportemental. Ils font appel à la régression linéaire multivariée pour comprendre la variation du fonctionnement des adolescents selon la durée d'utilisation et les caractéristiques de dépendance d'utilisation. RÉSULTATS: Le temps d'écran total moyen s'élevait à 4,5±2,4 heures/jour. Les caractéristiques de dépendance d'utilisation étaient constamment corrélées avec une atteinte fonctionnelle démontrée par des mesures multiples et par les informateurs, tandis que la durée d'utilisation, abstraction faite de la dépendance, ne l'était pas. CONCLUSIONS: Chaque jour, les adolescents passent de nombreuses heures devant un écran. En l'absence de caractéristiques de dépendance à l'égard de l'utilisation de l'ordinateur et des consoles de jeu, le temps consacré n'est pas corrélé avec des problèmes, mais les adolescents qui présentent des caractéristiques de dépendance d'utilisation ont des manifestations de mauvais fonctionnement affectif et comportemental.

Trainees' perceptions of patient safety practices: recounting failures of supervision.

BACKGROUND: Ensuring that trainees receive appropriate clinical supervision is one proven method for improving patient safety outcomes. Yet, supervision is difficult to monitor, even more so during advanced levels of training. The manner in which trainees' perceived failures of supervision influenced patient safety practices across disciplines and various levels of training was investigated. METHODS: A brief, open-ended questionnaire, administered to 334 newly hired interns, residents, and fellows, asked for descriptions of situations in which they witnessed a failure of supervision and their corresponding response. RESULTS: Of the 265 trainees completing the survey, 73 (27.5%) indicated having witnessed a failure of supervision. The analysis of these responses revealed three types of supervision failures-monitoring, guidance, and feedback. The necessity of adequate supervision and its accompanying consequences were also highlighted in the participants responses. CONCLUSIONS: The findings of this study identify two primary sources of failures of supervision: supervisors' failure to respond to trainees' seeking of guidance or clinical support and trainees' failure to seek such support. The findings suggest that the learning environment's influence was sufficient to cause trainees to value their appearance to superiors more than safe patient care, suggesting that trainees' feelings may supersede patients' needs and jeopardize optimal treatment. The literature on the impact of disruptive behavior on patient care may also improve understanding of how intimidating and abusive behavior stifles effective communication and trainees' ability to provide optimal patient care. Improved supervision and communication within the medical hierarchy should not only create more productive learning environments but also improve patient safety.

The screens culture: impact on ADHD.

Children's use of electronic media, including Internet and video gaming, has increased dramatically to an average in the general population of roughly 3 h per day. Some children cannot control their Internet use leading to increasing research on "internet addiction." The objective of this article is to review the research on ADHD as a risk factor for Internet addiction and gaming, its complications, and what research and methodological questions remain to be addressed. The literature search was done in PubMed and Psychinfo, as well as by hand. Previous research has demonstrated rates of Internet addiction as high as 25% in the population and that it is addiction more than time of use that is best correlated with psychopathology. Various studies confirm that psychiatric disorders, and ADHD in particular, are associated with overuse, with severity of ADHD specifically correlated with the amount of use. ADHD children may be vulnerable since these games operate in brief segments that are not attention demanding. In addition, they offer immediate rewards with a strong incentive to increase the reward by trying the next level. The time spent on these games may also exacerbate ADHD symptoms, if not directly then through the loss of time spent on more developmentally challenging tasks. While this is a major issue for many parents, there is no empirical research on effective treatment. Internet and off-line gaming overuse and addiction are serious concerns for ADHD youth. Research is limited by the lack of measures for youth or parents, studies of children at risk, and studies of impact and treatment.

Life-threatening critical respiratory events: a retrospective study of postoperative patients found unresponsive during analgesic therapy.

STUDY OBJECTIVE: To identify risk factors for life-threatening critical respiratory events occurring during parenteral analgesic therapy for acute postoperative pain. DESIGN: Retrospective, observational, cohort study. SETTING: University hospital. MEASUREMENTS: The electronic records of patients with sudden-onset, life-threatening critical respiratory events during analgesic therapy for postoperative pain were studied. Critical respiratory event data were identified from the hospital risk management database between 8/1/2000 and 7/31//2007. Patients required rescue treatment with naloxone, endototracheal intubation, or cardiopulmonary resusucitation. Pediatric patients were excluded from the study. In addition to the event description (type of analgesia, opioid dose, patient monitoring data, time of day, and time from surgery), each patient's record was reviewed to extract co-morbidities and outcome data. MAIN RESULTS: Over the 6-year period, 32 patients experienced a postoperative critical respiratory event. Twenty-six events and three deaths occurred within the first 24 hours of opioid therapy. Four of 32 patients died. Congestive heart failure, postoperative acute renal failure, obstructive sleep apnea, cardiac dysrhythmia, diabetes mellitus, coronary artery disease, and hypertension were significant associations in adult patients. CONCLUSIONS: The first 24 hours after commencing opioid-based analgesic therapy represents a high risk period. Obstructive sleep apnea, deep levels of sedation, nocturnal presentation, and postoperative acute renal failure were seen in patients who died as a result of these critical respiratory events.

Mainstreaming risk management education into new resident and fellow orientation.

INTRODUCTION: Understanding patient safety events and causative factors is an important step in reducing preventable adverse events. The University of Michigan's Graduate Medical Education (GME) Office, Department of Risk Management (DRM), and Office of Clinical Affairs (OCA) collaborated to incorporate a video workshop as a formal introduction to patient safety during orientation for new residents and fellows. This workshop reinforced the importance of effective communication and supervision in patient safety. METHODS: DRM and OCA produced a video depicting an actual, unanticipated outcome that resulted from a constellation of preventable circumstances, which allows the audience to observe communication and supervision issues that lead to a patient death. The video is followed by a discussion of the patient safety issues seen, why they occurred, and strategies for improvement. Trainee perceptions of the value of the experience were surveyed and collected using a qualitative survey. RESULTS: Most responders found the video workshop helpful. Trainees perceived the video and facilitated discussion as an effective way to identify patient safety issues, available resources, and the culture of patient safety at the institution. CONCLUSION: Trainee comments supported the video workshop as an effective way to highlight the importance of communication and supervision in relation to patient safety. In the future, the DRM, OCA, and GME hope to reinforce this shared vision of patient safety through combined educational efforts.

Automated notification of suspected obstructive sleep apnea patients to the perioperative respiratory therapist: a pilot study.

BACKGROUND: Obstructive sleep apnea (OSA) increases the risk of central and obstructive apneas after anesthesia, but the vast majority of patients with OSA are undiagnosed preoperatively. Current guidelines promote the use of postoperative continuous positive airway pressure (CPAP) in patients with OSA. Owing to the complex postoperative requirements of these patients, respiratory therapists (RTs) could substantially improve these patients' clinical management in the immediate postoperative period. We describe a system that identifies patients with suspected or documented OSA and automatically alerts the perioperative RT. METHODS: Patients who presented for surgery were preoperatively assessed, and if the patient had a diagnosis of OSA or OSA risk factors, the perioperative RT automatically received a paging alert, after the surgery. The RT reviewed the patient postoperatively and instituted CPAP or bi-level positive airway pressure (BiPAP), as indicated. We collected data on triggers for the automated alerts and utilization of CPAP and BiPAP. We reviewed risk-management data to analyze the effect of this intervention on postsurgical sudden-onset acute respiratory compromise. RESULTS: Of 7,422 patients who presented for surgery over a 5-month period, 766 had an OSA diagnosis or OSA risk factors. There were an average of 7-8 alerts per work day (range 2-18 alerts per day). On average, 2 patients per day were treated with CPAP/BiPAP in the post-anesthesia care unit or the postoperative general ward as a result of the alerts. The median paging alert time was 10:30 am. There were no episodes of sudden-onset postoperative acute respiratory compromise after institution of the OSA alert system. CONCLUSIONS: As part of a hospital-wide postoperative policy, our automated OSA alert and perioperative RT system helped prevent sudden-onset acute respiratory compromise in postoperative patients with OSA or at risk of OSA.