Effect of a Real-Time Pediatric ICU Safety Bundle Dashboard on Quality Improvement Measures.

BACKGROUND: Patient daily goal sheets have been shown to improve compliance with hospital policies but might not represent the dynamic nature of care delivery in the pediatric ICU (PICU) setting. A study was conducted at Children's National Health System (Washington, DC) to determine the effect of a visible, unitwide, real-time dashboard on timeliness of compliance with quality and safety measures. METHODS: An automated electronic health record (EHR)- querying tool was created to assess compliance with a PICU Safety Bundle. Querying of the EHR for compliance and updating of the dashboard automatically occurred every five minutes. A real-time visual display showed data on presence of consent for treatment, restraint orders, presence of urinary catheters, deep venous thrombosis (DVT) prophylaxis, Braden Q score, and medication reconciliation. Baseline compliance and duration of noncompliance was established during three time periods: the first, before activation of the dashboard; the second, at one month following activation of the dashboard; and the third, at three months after activation. RESULTS: A total of 450 patients were included in the analysis. Between the first and third time periods, the median time from PICU admission to obtaining treatment consent decreased by 49%, from 393 to 202 minutes (p=.05). The number of patients with urinary catheters in place>96 hours decreased from 16 (32%) in Period 1 to 11 (19%) for Periods 2 and 3 combined (p=.01). Completion of medication reconciliation improved from 80% in the first time period to 93% and 92%, respectively, in the subsequent two periods (p=.002). There was no difference between the three periods in presence of restraint orders, DVT prophylaxis, or development or worsening of pressure ulcers. CONCLUSIONS: A unitwide dashboard can increase awareness for potential interventions, affecting patient safety in the PICU in a dynamic manner.

Extracorporeal life support for a 5-week-old infant with idiopathic pulmonary hemosiderosis.

UNLABELLED: Idiopathic pulmonary hemosiderosis is a rare disease defined by the triad of iron deficiency anemia, hemoptysis, and diffuse pulmonary infiltrates on chest radiograph. Idiopathic pulmonary hemosiderosis is known to cause dyspnea and, in some cases, acute onset of massive pulmonary hemorrhage which is traditionally treated with conventional mechanical ventilation or high-frequency oscillation in conjunction with immunosuppressive therapy. In this case report, we describe a 5-week-old infant presenting with hemoptysis, massive pulmonary hemorrhage, and significant hypercapnic respiratory failure. The patient failed conventional ventilation but responded well to extracorporeal life support that was initiated early in his course. Idiopathic pulmonary hemosiderosis was suspected in light of his response to high-dose steroids and was confirmed by subsequent lung biopsies. CONCLUSION: Patients with severe pulmonary hemorrhage secondary to idiopathic pulmonary hemosiderosis can be safely supported with extracorporeal life support when conventional therapies have been exhausted.

Association of race and ethnicity with pediatric burn outcomes: A population study of the Kids' Inpatient Database.

BACKGROUND: While most studies on burn outcomes have focused on adults, it is unclear if the same socioeconomic and environmental inequalities affect paediatric patients. This study aims to investigate the impact of race and ethnicity on outcomes in paediatric burn patients. METHODS: The Kids' Inpatient Database is released by Agency for Healthcare Research and Quality, and is the largest publicly available database for the United States inpatient paediatric population. All paediatric burned patients in 2016 and 2019 were identified. Race and/or ethnicity was the primary exposure variable, and the primary outcome was a composite of several in-hospital morbidities. Secondary outcomes included death, non-routine disposition, and length of stay. Fine-Gray competing risks regression and multivariable logistic regression were used to analyze length of stay and all other outcomes, respectively. Analysis also isolated subgroups related to socioeconomic status and case severity. RESULTS: We included12,582 pediatric burn patients in this study. No difference was found in composite morbidity between White patients and those of other race or ethnicity groups. Hispanic ethnicity was associated with longer lengths of stay and increased odds of routine (i.e. home) discharge. Black patients had increased length of stay compared to White patients only in severe burn cases. CONCLUSIONS: Our study implies that race- or ethnicity-associated mechanisms driving outcome disparities in adults does not necessarily apply in paediatric burn patients.

Does caudal analgesia improve pain control for pediatric burn surgery: A retrospective study.

Pediatric burns affect approximately 15-20 patients per 100 000 hospital admissions, but unfortunately there is a lack of evidence to guide optimal strategies for acute pain control. The aim of this study was to evaluate whether caudal analgesia with single injection of local anesthetics reduced pain medication consumption in pediatric patients who required surgical intervention for burn injuries. Retrospective data from patients <7 years old who had burn surgery in the operating rooms at a single regional burn center from 2013 to 2021 was obtained and analyzed. A 1:1 propensity-score matching method using nearest neighbor matching without replacement was utilized to create matched cohorts. Primary outcome was opioid consumption, which is presented as opioid equivalents divided by patient weight in kilograms, at 24 h after surgery. Comparing propensity-score matched groups, there were no statistically significant differences in adjusted morphine equivalents received by the caudal group (0.122 [0.0646;0.186]) and the no caudal group (0.0783 [0.0384;0.153]) at 24 h after surgery (p = 0.06). This is the first study to the best of our knowledge of the association of caudal analgesia in pediatric burn patients with postoperative pain control. The data showed an increase in pain medication consumption postoperative at 24 h and intraoperative for patients who received single injection caudal blocks, but when adjusted using propensity-score matching, the difference was no longer statistically significant.

Anesthesia for Major Surgery in the Neonate.

Perioperative risk of morbidity and mortality for neonates is significantly higher than that for older children and adults. At particular risk are neonates born prematurely, neonates with major or severe congenital heart disease, and neonates with pulmonary hypertension. Presently no consensus exists regarding the safest anesthetic regimen for neonates. Regional anesthesia appears to be safe, but does not reduce the overall risk of postoperative apnea. Former preterm infants require postoperative observation for apnea. The anesthesiologist caring for the neonate for major surgery should be knowledgeable of the unique physiology of the neonate and maintain the highest level of vigilance throughout.

Pediatric Perioperative DNR Orders: A Case Series in a Children's Hospital.

CONTEXT: Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period are limited. OBJECTIVES: To evaluate perioperative management of DNR orders at a tertiary care children's hospital. METHODS: We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from February 1, 2016, to August 1, 2017. Using standardized case report forms, we abstracted the following from physician notes: 1) patient/family wishes with respect to the DNR, 2) whether preoperative DNR orders were continued, modified, or suspended during the perioperative period, and 3) whether life-threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision-making in the perioperative period. RESULTS: Twenty-three patients aged six days to 17 years had a DNR order in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures and suspended for 15 (51%). Three children (13%) suffered life-threatening events. We identified four time points in the perioperative period where systematic reconsideration should be documented in the medical record, and identified recommended personnel involved and important discussion points at each time point. CONCLUSION: Opportunities exist to improve how DNR orders are managed during the perioperative period.