Airway management in paediatric emergencies outside of an intensive care setting: a quality improvement project using Lean/Six Sigma methodology.

Use of a Lean/Six Sigma methodology in a quality improvement project to reduce variation and improve safety in airway management outside of the intensive care environment in a tertiary paediatric hospital.

Association Between Treatments and Short-Term Biochemical Improvements and Clinical Outcomes in Post-Severe Acute Respiratory Syndrome Coronavirus-2 Inflammatory Syndrome.

OBJECTIVES: To 1) analyze the short-term biochemical improvements and clinical outcomes following treatment of children with post-severe acute respiratory syndrome coronavirus-2 inflammatory syndrome (multisystem inflammatory syndrome in children/pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2) admitted to U.K. PICUs and 2) collate current treatment guidance from U.K. PICUs. DESIGN: Multicenter observational study. SETTING: Twenty-one U.K. PICUs. PATIENTS: Children (< 18 yr) admitted to U.K. PICUs between April 1, 2020, and May 10, 2020, fulfilling the U.K. case definition of pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Routinely collected, deidentified data were analyzed. Propensity score and linear mixed effects models were used to analyze the effect of steroids, IV immunoglobulin, and biologic agents on changes in C-reactive protein, platelet counts, and lymphocyte counts over the course of PICU stay. Treatment recommendations from U.K. clinical guidelines were analyzed. Over the 6-week study period, 59 of 78 children (76%) received IV immunoglobulin, 57 of 78 (73%) steroids, and 18 of 78 (24%) a biologic agent. We found no evidence of a difference in response in clinical markers of inflammation between patients with multisystem inflammatory syndrome in children/pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 who were treated with IV immunoglobulin, steroids, or biologics, compared with those who were not. By the end of the study period, most patients had received immunomodulation. The 12 patients who did not receive any immunomodulators had similar decrease in inflammatory markers as those treated. Of the 14 guidelines analyzed, the use of IV immunoglobulin, steroids, and biologics was universally recommended. CONCLUSIONS: We were unable to identify any short-term benefit from any of the treatments, or treatment combinations, administered. Despite a lack of evidence, treatment guidelines for multisystem inflammatory syndrome in children/pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2 have become very similar in advising step-wise treatments. Retaining clinical equipoise regarding treatment will allow clinicians to enroll children in robust clinical trials to determine the optimal treatment for this novel important condition.

The optimisation of paediatric CT examinations in Scotland: phase one; benchmarking current performance.

To benchmark the dose from paediatric head and chest examinations on computed tomography (CT) scanners throughout Scotland, to identify scanners that may require optimisation and to provide optimisation advice based on the protocols from better performing scanners. Anthropomorphic phantoms corresponding to 1, 5 and 10 year olds were sent to 50 CT scanners around Scotland. Head and chest examinations were undertaken by local staff using local techniques on each scanner with each phantom, and details of the protocols used were recorded. Computed tomography dose index (CTDI)voland dose length product (DLP) were recorded post-scan. There is a significant variation in performance throughout Scotland. For head examinations, the highest DLP is 13 times the lowest for an equivalent sized phantom. For chest examinations, the highest is 128 times the lowest for an equivalent sized phantom. The wide range of CT dose measurements indicates the potential for variation in image quality across Scotland. Feedback has been provided to all participating sites on their individual results compared to the national data set. Specific feedback was provided where relevant on potential considerations for optimisation. Scanners that may be undertaking paediatric CT head and chest examinations in a sub-optimal manner throughout Scotland have been identified along with those aspects of a scan protocol that are most likely to lead to sub-optimal performance.

Well-Being During Coronavirus Disease 2019: A PICU Practical Perspective.

The importance of promoting well-being for healthcare professionals has never been as important as during the current coronavirus disease 2019 pandemic. It is recognized that the concept of well-being is a multifaceted phenomenon which is influenced by individual, team, and system characteristics. We outline an approach to practically initiating supportive strategies within the PICU using a well-being approach to improve baseline resilience alongside an acute rescue strategy utilizing a peer-support network. These strategies are practical interventions and we share them with the aim of encouraging the international PICU community to use these or other strategies to support their teams. We encourage shared learning and collaboration during these difficult times.

Can critical care transport be safely reduced in children intubated during emergency management of status epilepticus in the United Kingdom: a national audit with case-control analysis.

OBJECTIVE: This study describes the baseline clinical characteristics, predictors of successful extubation at referring hospitals and short-term outcomes of children intubated for status epilepticus and referred to United Kingdom (UK) paediatric critical care transport teams (PCCTs). DESIGN: Multicentre audit with case-control analysis, conducted between 1 September 2018 and 1 September 2020. SETTING: This study involved 10 UK PCCTs. PATIENTS: Children over 1 month of age intubated during emergency management for status epilepticus (SE), referred to UK PCCTs. Patients with trauma, requiring time-critical neurosurgical intervention or those with a tracheostomy were excluded. INTERVENTIONS: No interventions were implemented. MEASUREMENTS AND MAIN RESULTS: Out of the 1622 referrals for SE, 1136 (70%) were intubated at referral. The median age was 3 years (IQR 1.25-6.54 years). Among the intubated children, 396 (34.8%) were extubated locally by the referring team, with 19 (4.8%) requiring reintubation. Therefore, the overall rate of successful extubation was 33% (377/1136). There was significant variation between PCCTs, with local extubation rates ranging from 2% to 74%. Multivariable analyses showed region/PCCT, contributing diagnosis, acute changes on CT, preceding encephalopathy and type of continuous sedation (midazolam) used postintubation were significantly associated with transfer to a critical care unit. CONCLUSION: This study highlights wide regional variation in early extubation practices. Regions with high successful extubation rates have established extubation guidelines from PCCTs. Successful extubation represents critical care transports that have been avoided.

Analysis and results from a UK national dose audit of paediatric CT examinations.

OBJECTIVE: To present the results following a UK national patient dose audit of paediatric CT examinations, to propose updated UK national diagnostic reference levels (DRLs) and to analyse current practice to see if any recommendations can be made to assist with optimisation. METHODS: A UK national dose audit was undertaken in 2019 focussing on paediatric CT examinations of the head, chest, abdomen/pelvis and cervical spine using the methods proposed by the International Commission on Radiological Protection. The audit pro-forma contained mandatory fields, of which the post-examination dosimetry (volume CT dose index and dose-length product) and the patient weight (for body examinations) were the most important. RESULTS: Analysis of the data submitted indicates that it is appropriate to propose national DRLs for CT head examinations in the 0-<1, 1-<5, 5-<10 and 10-<15 year age ranges. This extends the number of age categories of national DRLs from those at present and revises the existing values downwards. For CT chest examinations, it is appropriate to propose national DRLs for the first time in the UK for the 5-<15, 15-<30, 30-<50 and 50-<80 kg weight ranges. There were insufficient data received to propose national DRLs for abdomen/pelvis or cervical spine examinations. Recommendations towards optimisation focus on the use of tube current (mA) modulation, iterative reconstruction and the selection of examination tube voltage (kVp). CONCLUSION: Updated UK national DRLs are proposed for paediatric CT examinations of the head and chest. ADVANCES IN KNOWLEDGE: A national patient dose audit of paediatric CT examinations has led to the proposal of updated national DRLs.

Determining patient abdomen thickness from a single digital radiograph with a computational model: clinical results from a proof of concept study.

OBJECTIVE: A computational model has been created to estimate the abdominal thickness of a patient following an X-ray examination; its intended application is assisting with patient dose audit of paediatric X-ray examinations. This work evaluates the accuracy of the computational model in a clinical setting for adult patients undergoing anteroposterior (AP) abdomen X-ray examinations. METHODS: The model estimates patient thickness using the radiographic image, the exposure factors with which the image was acquired, a priori knowledge of the characteristics of the X-ray unit and detector and the results of extensive Monte Carlo simulation of patient examinations. For 20 patients undergoing AP abdominal X-ray examinations, the model was used to estimate the patient thickness; these estimates were compared against a direct measurement made at the time of the examination. RESULTS: Estimates of patient thickness made using the model were on average within ±5.8% of the measured thickness. CONCLUSION: The model can be used to accurately estimate the thickness of a patient undergoing an AP abdominal X-ray examination where the patient's size falls within the range of the size of patients used to create the computational model. ADVANCES IN KNOWLEDGE: This work demonstrates that it is possible to accurately estimate the AP abdominal thickness of an adult patient using the digital X-ray image and a computational model.

IPEM Topical Report: An evidence and risk assessment based analysis of the efficacy of quality assurance tests on fluoroscopy units-part II; image quality.

This work aims to assess the efficacy of x-ray quality assurance tests undertaken on fluoroscopy units in the UK. Information was gathered on the results of image quality tests recommended by the reports of the Institute of Physics and Engineering in Medicine, and those additionally undertaken by medical physics departments. The assessment of efficacy considers the frequency with which a test result breaches the remedial level or other relevant threshold where applicable. The third quartile of those results exceeding the remedial level or threshold is used to estimate the severity of such a breach in terms of potential impact on patient dose and image quality. A risk assessment approach is then used to recommend to what degree, if any, the test should be included in an on-going test regimen. Data was analysed from 469 testing sessions to 337 unique fluoroscopy units throughout the UK. Across all tests, the rate with which the remedial level was exceeded varied from 0-10.6%, with severity ranging from little or none to major degradation to image quality or significant increase on population dose. Where possible, the data has also been used to produce representative ranges for the results of image quality tests. These could be useful as an up to date comparator for those sites considering the purchase of or commissioning new equipment. Overall the results indicate a wide range for the efficacy of those tests undertaken at present; this can be used to review local test protocols and to inform future changes to national guidance in the UK. The results also highlight some tests where measurement technique varies significantly throughout the UK, making any valid comparison difficult. This may indicate a need for further guidance on how best to undertake these tests.

Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multicentre observational study.

BACKGROUND: In April, 2020, clinicians in the UK observed a cluster of children with unexplained inflammation requiring admission to paediatric intensive care units (PICUs). We aimed to describe the clinical characteristics, course, management, and outcomes of patients admitted to PICUs with this condition, which is now known as paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS). METHODS: We did a multicentre observational study of children (aged <18 years), admitted to PICUs in the UK between April 1 and May 10, 2020, fulfilling the case definition of PIMS-TS published by the Royal College of Paediatrics and Child Health. We analysed routinely collected, de-identified data, including demographic details, presenting clinical features, underlying comorbidities, laboratory markers, echocardiographic findings, interventions, treatments, and outcomes; serology information was collected if available. PICU admission rates of PIMS-TS were compared with historical trends of PICU admissions for four similar inflammatory conditions (Kawasaki disease, toxic shock syndrome, haemophagocytic lymphohistiocytosis, and macrophage activation syndrome). FINDINGS: 78 cases of PIMS-TS were reported by 21 of 23 PICUs in the UK. Historical data for similar inflammatory conditions showed a mean of one (95% CI 0·85-1·22) admission per week, compared to an average of 14 admissions per week for PIMS-TS and a peak of 32 admissions per week during the study period. The median age of patients was 11 years (IQR 8-14). Male patients (52 [67%] of 78) and those from ethnic minority backgrounds (61 [78%] of 78) were over-represented. Fever (78 [100%] patients), shock (68 [87%]), abdominal pain (48 [62%]), vomiting (49 [63%]), and diarrhoea (50 [64%]) were common presenting features. Longitudinal data over the first 4 days of admission showed a serial reduction in C-reactive protein (from a median of 264 mg/L on day 1 to 96 mg/L on day 4), D-dimer (4030 µg/L to 1659 µg/L), and ferritin (1042 µg/L to 757 µg/L), whereas the lymphocyte count increased to more than 1·0 × 109 cells per L by day 3 and troponin increased over the 4 days (from a median of 157 ng/mL to 358 ng/mL). 36 (46%) of 78 patients were invasively ventilated and 65 (83%) needed vasoactive infusions; 57 (73%) received steroids, 59 (76%) received intravenous immunoglobulin, and 17 (22%) received biologic therapies. 28 (36%) had evidence of coronary artery abnormalities (18 aneurysms and ten echogenicity). Three children needed extracorporeal membrane oxygenation, and two children died. INTERPRETATION: During the study period, the rate of PICU admissions for PIMS-TS was at least 11-fold higher than historical trends for similar inflammatory conditions. Clinical presentations and treatments varied. Coronary artery aneurysms appear to be an important complication. Although immediate survival is high, the long-term outcomes of children with PIMS-TS are unknown. FUNDING: None.

VALIDATION OF A BEAMNRC MONTE CARLO SIMULATION OF A BROAD BEAM DIAGNOSTIC X-RAY UNIT.

A BEAMnrc Monte Carlo simulation of a diagnostic X-ray unit in a broad beam geometry intended for the derivation of effective linear attenuation coefficients was validated against measurements made on the X-ray unit on which the simulation was based. The validation process assessed the size of the beam, the first and second half value layer, the variation in kerma with anode-heel effect and the accuracy of values of effective linear attenuation coefficient for water and solid water attenuators. The agreement between the simulated and measured results for all tests was consistently within the experimental uncertainty for the measurements. The average deviation between values of effective linear attenuation coefficient for simulated and measured results is 3.8%, with the highest individual deviation 7.1%. The simulation can be used to produce values of effective linear attenuation coefficient for a range of kVp, field size and attenuator thickness that are close to those measured.

IPEM Topical Report: an evidence and risk assessment based analysis of the efficacy of quality assurance tests on fluoroscopy units-part I; dosimetry and safety.

This work aims to assess the efficacy of x-ray quality assurance tests undertaken on fluoroscopy units in the UK. Information was gathered on the results of dosimetry and safety tests recommended by the reports of the Institute of Physics and Engineering in Medicine, and those additionally undertaken by medical physics departments. The assessment of efficacy considers the frequency with which a test result breaches the remedial level or other relevant threshold where applicable. The third quartile of those results exceeding the remedial level or threshold is used to estimate the severity of such a breach in terms of potential impact on patient dose and image quality. A risk assessment approach is then used to recommend to what degree, if any, the test should be included in an on-going test regimen. Data was analysed from 468 testing sessions to 336 unique fluoroscopy units throughout the UK. Across all tests, the rate with which the remedial level was exceeded varied from 0%-29.5%, with severity ranging from little or none to major degradation to image quality or significant increase on population dose. Where possible, the data has also been used to produce representative ranges for the results of dosimetric tests. These could be useful as an up to date comparator for those sites considering the purchase of or commissioning new equipment. Overall the results indicate a wide range for the efficacy of those tests undertaken at present; this can be used to review local test protocols and to inform future changes to national guidance in the UK. The results also highlight some tests where measurement technique varies significantly throughout the UK, making any valid comparison difficult. This may indicate a need for further guidance on how best to undertake these tests.

The use of a thyroid shield for intraoral anterior oblique occlusal views-a risk-based approach.

OBJECTIVES: To estimate the radiation dose reduction to the thyroid for an anterior oblique occlusal view from the use of a thyroid shield, compare this with the variation in thyroid dose resulting from differences in examination positioning and discuss the additional considerations associated with the use of a thyroid shield before making a recommendation on their routine use for this examination. METHODS: Doses to the oral mucosa, the salivary glands, the thyroid, the extrathoracic airways, the oesophagus and the lungs were directly measured for anterior oblique occlusal X-rays of a Rando phantom with and without a thyroid shield using strips of calibrated XRQA Gafchromic film. The examination was also simulated using Monte Carlo software for the without thyroid shield case for a comparison of the dose and to evaluate the dosimetric effect of suboptimal examination positioning. RESULTS: A 36% reduction in thyroid dose was measured as a result of thyroid shield use; the effective dose reduction is of the order of 22%. Suboptimal positioning was found to increase thyroid dose by a far more significant amount. CONCLUSIONS: Despite the reduction in thyroid dose, cost-benefit considerations mean that the purchase of a thyroid shield is only recommended where a very high number of anterior oblique occlusal views are undertaken. Optimization efforts for this examination are better focussed on training in examination positioning.

Determining paediatric patient thickness from a single digital radiograph-a proof of principle.

OBJECTIVE: This work presents a proof of principle for a method of estimating the thickness of an attenuator from a single radiograph using the image, the exposure factors with which it was acquired and a priori knowledge of the characteristics of the X-ray unit and detector used for the exposure. It is intended this could be developed into a clinical tool to assist with paediatric patient dose audit, for which a measurement of patient size is required. METHODS: The proof of principle used measured pixel value and effective linear attenuation coefficient to estimate the thickness of a Solid Water attenuator. The kerma at the detector was estimated using a measurement of pixel value on the image and measured detector calibrations. The initial kerma was estimated using a lookup table of measured output values. The effective linear attenuation coefficient was measured for Solid Water at varying kVp. 11 test images of known and varying thicknesses of Solid Water were acquired at 60, 70 and 81 kVp. Estimates of attenuator thickness were made using the model and the results compared to the known thickness. RESULTS: Estimates of attenuator thickness made using the model differed from the known thickness by 3.8 mm (3.2%) on average, with a range of 0.5-10.8 mm (0.5-9%). CONCLUSION: A proof of principle is presented for a method of estimating the thickness of an attenuator using a single radiograph of the attenuator. The method has been shown to be accurate using a Solid Water attenuator, with a maximum difference between estimated and known attenuator thickness of 10.8 mm (9%). The method shows promise as a clinical tool for estimating abdominal paediatric patient thickness for paediatric patient dose audit, and is only contingent on the type of data routinely collected by Medical Physics departments. Advances in knowledge: A computational model has been created that is capable of accurately estimating the thickness of a uniform attenuator using only the radiographic image, the exposure factors with which it was acquired and a priori knowledge of the characteristics of the X-ray unit and detector used for the exposure.

IPEM Topical Report: an evidence and risk assessment based analysis of the efficacy of tube and generator quality assurance tests on general x-ray units.

This work aims to assess the efficacy of current x-ray quality assurance (QA) testing regimes on tube and generator systems for general radiographic usage in the UK. 1393 sets of QA results data from nine UK medical physics departments were collected and analysed. Test failure rates ranged from 0% to 39% and were used to assess the likelihood of the test finding a fault. The magnitude of the recorded faults were used to assess the severity of the failure with due consideration to its impact on image quality and patient dose. The severity and likelihood of the faults were used along with a risk matrix to assess the efficacy of each test. Eleven tests were graded 'orange' (indicating an effective test that should be continued), four tests were graded 'yellow' (indicating a less effective test that may be continued with a lower frequency considered) and four tests were graded green (indicating a low efficacy test that could be removed from test regimes).