Diagnostic Stewardship of Endotracheal Aspirate Cultures in a PICU.

BACKGROUND: Clinicians commonly obtain endotracheal aspirate cultures (EACs) in the evaluation of suspected ventilator-associated infections. However, bacterial growth in EACs does not distinguish bacterial colonization from infection and may lead to overtreatment with antibiotics. We describe the development and impact of a clinical decision support algorithm to standardize the use of EACs from ventilated PICU patients. METHODS: We monitored EAC use using a statistical process control chart. We compared the rate of EACs using Poisson regression and a quasi-experimental interrupted time series model and assessed clinical outcomes 1 year before and after introduction of the algorithm. RESULTS: In the preintervention year, there were 557 EACs over 5092 ventilator days; after introduction of the algorithm, there were 234 EACs over 3654 ventilator days (an incident rate of 10.9 vs 6.5 per 100 ventilator days). There was a 41% decrease in the monthly rate of EACs (incidence rate ratio [IRR]: 0.59; 95% confidence interval [CI] 0.51-0.67; P < .001). The interrupted time series model revealed a preexisting 2% decline in the monthly culture rate (IRR: 0.98; 95% CI 0.97-1.0; P = .01), immediate 44% drop (IRR: 0.56; 95% CI 0.45-0.70; P = .02), and stable rate in the postintervention year (IRR: 1.03; 95% CI 0.99-1.07; P = .09). In-hospital mortality, hospital length of stay, 7-day readmissions, and All Patients Refined Diagnosis Related Group severity and mortality scores were stable. The estimated direct cost savings was $26 000 per year. CONCLUSIONS: A clinical decision support algorithm standardizing EAC obtainment from ventilated PICU patients was associated with a sustained decline in the rate of EACs, without changes in mortality, readmissions, or length of stay.

Transforming a PICU Into an Adult ICU During the Coronavirus Disease 2019 Pandemic: Meeting Multiple Needs.

We describe the process converting half of our 40-bed PICU into a negative-pressure biocontainment ICU dedicated to adult coronavirus disease 2019 patients within a 1,003-bed academic quaternary hospital. We outline the construction, logistics, supplies, provider education, staffing, and operations. We share lessons learned of working with a predominantly pediatric staff blended with adult expertise staff while maintaining elements of family-centered care typical of pediatric critical care medicine. Critically ill coronavirus disease 2019 adult patients may be cared for in a PICU and care may be augmented by implementing elements of holistic, family-centered PICU practice.

Is antibiotic prophylaxis necessary in elective soft tissue hand surgery?

Antibiotic prophylaxis for clean soft tissue hand surgery is not yet defined. Current literature focuses on overall orthopedic procedures, traumatic hand surgery, and carpal tunnel release. However, a paucity of data exists regarding the role of antibiotic prophylaxis in a broader variety of soft tissue hand procedures. The goal of the current study was to evaluate the rates of surgical site infection following elective soft tissue hand surgery with respect to administration of prophylactic antibiotics.A multicenter, retrospective review was performed on 600 consecutive elective soft tissue hand procedures. Procedures with concomitant implant or incomplete records were excluded. Antibiotic delivery was given at the discretion of the attending surgeon. Patient comorbidities were recorded. Outcomes were measured by the presence of deep or superficial infections within 30 days postoperatively. The 4 most common procedures were carpal tunnel release, trigger finger release, mass excision, and first dorsal compartment release. The overall infection rate was 0.66%. All infections were considered superficial, and none required surgical management. In patients who received antibiotic prophylaxis (n=212), the infection rate was 0.47%. In those who did not receive prophylaxis (n=388), the infection rate was 0.77%. These differences were not statistically significant (P=1.00).

Critical evaluation of emergency stockpile ventilators in an in vitro model of pediatric lung injury.

OBJECTIVE: Modern health care systems may be inadequately prepared for mass casualty respiratory failure requiring mechanical ventilation. Current health policy has focused on the "stockpiling" of emergency ventilators, though little is known about the performance of these ventilators under conditions of respiratory failure in adults and children. In this study, we seek to compare emergency ventilator performance characteristics using a test lung simulating pediatric lung injury. DESIGN: Evaluation of ventilator performance using a test lung. SETTING: Laboratory. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six transport/emergency ventilators capable of adult/child application were chosen on the basis of manufacturer specifications, Autovent 3000, Eagle Univent 754, EPV 100, LP-10, LTV 1200, and Parapac 200D. Manufacturer specifications for each ventilator were reviewed and compared with known standards for alarms and functionality for surge capacity ventilators. The delivered tidal volume, gas flow characteristics, and airway pressure waveforms were evaluated in vitro using a mechanical test lung to model pediatric lung injury and integrated software. Test lung and flow meter recordings were analyzed over a range of ventilator settings. Of the six ventilators assessed, only two had the minimum recommended alarm capability. Four of the six ventilators tested were capable of being set to deliver a tidal volume of less than 200 mL. The delivered tidal volume for all ventilators was within 8% of the nominal setting at a positive end expiratory pressure of zero but was reduced significantly with the addition of positive end expiratory pressure (range, ±10% to 30%; p < .01). All ventilators tested performed comparably at higher set tidal volumes; however, only three of the ventilators tested delivered a tidal volume across the range of ventilator settings that was comparable to that of a standard intensive care unit ventilator. CONCLUSIONS: Multiple ventilators are available for the provision of ventilation to children with respiratory failure in a mass casualty scenario. Few of these ventilators possess the minimum alarm functionality and consistently deliver the prescribed tidal volume that allows for safe and effective ventilation of critically ill pediatric patients. These findings will help clinicians understand the performance and limitations of available ventilators intended for use in children.

Quality of clinical photographs taken by orthodontists, professional photographers, and orthodontic auxiliaries.

INTRODUCTION: A survey of the members of the Angle Society of Europe showed that 60% of orthodontists took their own clinical photographs, 35% assigned the task to an auxiliary, and 5% hired professional clinical photographers. It is always useful to ensure that orthodontists' time is used to maximum effect. Clinical photography could be delegated to auxiliary staff. In this study, we assessed the quality of photographs taken by orthodontists to see whether those taken by orthodontic auxiliaries and clinical photographers are of comparable quality. METHODS: Fifty sets of orthodontic photographs were collected from each of 3 types of photographers: orthodontists, orthodontic auxiliaries, and professional clinical photographers. Four assessors scored each set for quality and detailed errors. The results were compared to determine whether there were differences between the quality of the photographs taken by the different groups. RESULTS AND CONCLUSIONS: Most of the photos taken by the 3 groups of photographers were judged to be good or acceptable. The results for extraoral photographs showed no statistically significant differences between the 3 groups for good (P = 0.398) and acceptable (P = 0.398) images. The results for intraoral photographs did not differ significantly for acceptable and unacceptable photographs, but orthodontists produced significantly more good-quality intraoral photographs (P = 0.046).