Management of Hospitalized Asthmatic Children Before Transport.

Asthmatic children are at risk for respiratory failure and should be appropriately treated before transport. The objectives were to find out if the Pediatric Advanced Life Support guidelines for asthma treatment were followed in the emergency department (ED); to determine if additional treatment during transport or within the first 2 hours of admission was needed; and to compare the management of intubated asthmatics by the ED, transport team, and the intensive care unit (ICU) physician. The records for children diagnosed with acute asthma over 7 years who were transported by the intensive care transport team were reviewed. The use of albuterol, steroids, oxygen, heliox, continuous positive airway pressure or bilevel positive airway pressure, and ventilator settings was recorded. Two hundred seventy-nine children were 7 years (age, 5 mo-17 y), and 62% were male. Eighty percent received oxygen, albuterol, and steroids in the ED. Heliox was initiated more often by the transport team when compared with the ED or hospital physician (77% vs. 7.7% vs. 15.3%, P < .0001). Forty-five were mechanically ventilated and were more likely to receive volume control (P < .0001) and higher rates (P = .007) in the ED than the ICU. We conclude that most children with acute asthma were treated with oxygen, albuterol, and steroids in the ED. If used, heliox was most likely started during transport. Intubated children were more likely to receive volume control with higher rates compared with lower rates and pressure control in the ICU.

Reducing Unplanned Extubations in a Level IV Neonatal Intensive Care Unit: The Elusive Benchmark.

Unplanned extubation (UE) is a common adverse event in the neonatal intensive care unit (NICU). At our level IV NICU, we initiated a quality improvement project in 2012 to reduce UE rates from 7.47 to below 100 intubated days. We describe the strategies used. METHODS: Multiple plan-do-study-act cycles were performed to address key drivers. Important interventions focused on staff education, consistent use of a new endotracheal (ET) tube securing device, 2 providers during bedside activities, documentation of ET tube position, and targeted sedation. Process measures included immediate root cause analyses for UE events and the use of the endotracheal tube securing device. The primary outcome was the UE rate per 100 intubated days. RESULTS: Over a nearly 6-year study period, quarterly UE rates decreased from 7.19 to 0.66 per 100 intubated days. The proportion of neonates requiring reintubation remained stable (64%-76%). Rates of root cause analysis completion and use of the ET securing device were more than 90% in the last 3 years of the study. The majority (61%) of UE events occurred in infants with birth weights greater than 2 kg, and 46% of infants had a prior UE. UE was associated with desaturation (50%), bradycardia (22%), and the need for resuscitation (7%). CONCLUSIONS: This quality improvement effort in a level IV NICU achieved a reduction in UE rates to below 1 per 100 intubated days after more than 5 years. Consistency in practices and widespread communication with the staff was critical to the effort.