Organisational culture: variation across hospitals and connection to patient safety climate.

CONTEXT: Bureaucratic organisational culture is less favourable to quality improvement, whereas organisations with group (teamwork) culture are better aligned for quality improvement. OBJECTIVE: To determine if an organisational group culture shows better alignment with patient safety climate. DESIGN: Cross-sectional administration of questionnaires. Setting 40 Hospital Corporation of America hospitals. PARTICIPANTS: 1406 nurses, ancillary staff, allied staff and physicians. MAIN OUTCOME MEASURES: Competing Values Measure of Organisational Culture, Safety Attitudes Questionnaire (SAQ), Safety Climate Survey (SCSc) and Information and Analysis (IA). RESULTS: The Cronbach alpha was 0.81 for the group culture scale and 0.72 for the hierarchical culture scale. Group culture was positively correlated with SAQ and its subscales (from correlation coefficient r = 0.44 to 0.55, except situational recognition), ScSc (r = 0.47) and IA (r = 0.33). Hierarchical culture was negatively correlated with the SAQ scales, SCSc and IA. Among the 40 hospitals, 37.5% had a hierarchical dominant culture, 37.5% a dominant group culture and 25% a balanced culture. Group culture hospitals had significantly higher safety climate scores than hierarchical culture hospitals. The magnitude of these relationships was not affected after adjusting for provider job type and hospital characteristics. CONCLUSIONS: Hospitals vary in organisational culture, and the type of culture relates to the safety climate within the hospital. In combination with prior studies, these results suggest that a healthcare organisation's culture is a critical factor in the development of its patient safety climate and in the successful implementation of quality improvement initiatives.

An intervention to decrease patient identification band errors in a children's hospital.

CONTEXT: Patient misidentification continues to be a quality and safety issue. There is a paucity of US data describing interventions to reduce identification band error rates. SETTING: Monroe Carell Jr Children's Hospital at Vanderbilt. KEY MEASURES: Percentage of patients with defective identification bands. STRATEGIES FOR CHANGE: Web-based surveys were sent, asking hospital personnel to anonymously identify perceived barriers to reaching zero defects with identification bands. Corrective action plans were created and implemented with ideas from leadership, front-line staff and the online survey. Data from unannounced audits of patient identification bands were plotted on statistical process control charts and shared monthly with staff. All hospital personnel were expected to "stop the line" if there were any patient identification questions. EFFECTS OF CHANGE: The first audit showed a defect rate of 20.4%. The original mean defect rate was 6.5%. After interventions and education, the new mean defect rate was 2.6%. LESSONS LEARNT: (a) The initial rate of patient identification band errors in the hospital was higher than expected. (b) The action resulting in most significant improvement was staff awareness of the problem, with clear expectations to immediately stop the line if a patient identification error was present. (c) Staff surveys are an excellent source of suggestions for combating patient identification issues. (d) Continued audit and data collection is necessary for sustainable staff focus and continued improvement. (e) Statistical process control charts are both an effective method to track results and an easily understood tool for sharing data with staff.

Extracorporeal membrane oxygenation in children after repair of congenital cardiac lesions.

BACKGROUND: The purpose of this study was to review our experience in the early application of extracorporeal membrane oxygenation (ECMO) in patients requiring mechanical assistance after cardiac surgical procedures. METHODS: The hospital records of all children requiring ECMO after cardiac operation were retrospectively reviewed, and an analysis of variables affecting survival was performed. RESULTS: Fifty pediatric patients between May 1997 and October 2000 required ECMO for cardiopulmonary support after cardiac operation. Patients ranged in age from 1 day to 11 years (median age, 40 days). Forty-eight patients underwent repair of congenital cardiac lesions and 2 were included after receiving a heart transplant. Twenty-two children could not be weaned from cardiopulmonary bypass and were placed on ECMO in the operating room for circulatory support. Of the 28 children who required ECMO in the intensive care unit, 10 had ECMO instituted after cardiopulmonary arrest (mean cardiopulmonary resuscitation time 42 minutes; range, 5 to 110 minutes). In infants with single-ventricle physiology, survival to discharge was 61% (11 of 18 patients) as compared with 43% (14 of 32 patients) in those with biventricular physiology. Thirty of the 50 patients (60%) were successfully weaned from ECMO, of which 25 (83%) were discharged home. Overall survival to discharge in the entire cohort was 50%. Extracorporeal membrane oxygenation support greater than 72 hours was a grave prognostic indicator. Overall survival in this group was 36% (9 of 25 patients) compared with 56% (14 of 25 patients) in those with ECMO support less than 72 hours (p < 0.05). Univariate analysis revealed the presence of renal failure, extended periods of circulatory support, and a prolonged period of cardiopulmonary resuscitation as risk factors for mortality. The presence of shunt-dependent flow, operative procedure, and institution of ECMO in the intensive care unit did not alter survival. CONCLUSIONS: Extracorporeal membrane oxygenation provides effective support for postoperative cardiac and pulmonary failure refractory to medical management. Early institution of ECMO may decrease the incidence of cardiac arrest and end-organ damage, thus increasing survival in these critically ill patients.

Clinical pathways and case management in anesthesia practice: new tools and systems for the evolving healthcare environment.

Clinical care pathways and case management are strategies utilized by increasing numbers of hospitals to meet the challenges of capitated reimbursement and managed care. A clinical pathway is an outcome-focused tool used to define a multidisciplinary plan of care. A case manager coordinates patient care across an episode of illness or hospitalization. These tools and systems have great potential for use by nurse anesthetists in ensuring that high-quality anesthesia care is delivered in a cost-effective manner.

Nicardipine versus nitroprusside for controlled hypotension during spinal surgery in adolescents.

Nicardipine or nitroprusside was used to induce controlled hypotension in healthy adolescents with idiopathic scoliosis undergoing spinal fusion. Twenty patients were randomly assigned to the nitroprusside (N) or nicardipine (C) group. All patients received a standardized anesthetic. A target mean arterial blood pressure (MAP) of 60 mm Hg was achieved by varying the vasoactive infusions only. Moderate hemodilution (PCV = 25) and intraoperative blood salvage were used in all cases. Hemodynamic variables, blood loss, occurrence of reflex tachycardia, and reversibility of the hypotensive state were compared between the two groups. Significant differences were observed between the two groups in the amount of blood loss and reversibility of the hypotensive state. Group C had less blood loss (761 +/- 199 mL) than Group N (1297.5 +/- 264, P < or = .05). Time to restoration of baseline MAP was longer with Group C (26.8 +/- 4.0 min) than Group N (7.3 +/- 1.1 min, P < or = 0.001). Both drugs rapidly achieved a stable, controlled hypotensive state and an acceptable operating field. There was no statistically significant difference between groups with respect to the amount of crystalloid administered or urine output. These results suggest that nicardipine is a safe, effective drug for controlled hypotension in this population and that it may offer the significant advantage of reduced blood loss in these patients.

Pentobarbital sedation for patients in the pediatric intensive care unit.

We present our experience with pentobarbital for sedation during mechanical ventilation in six infants when fentanyl and midazolam failed. The patients ranged in age from 2 to 17 months and in weight from 3.0 to 11.4 kg. Before the switch to pentobarbital, the maximum doses of fentanyl ranged from 7 to 13 micrograms/kg/hr and the midazolam infusions, from 0.2 to 0.4 mg/kg/hr. Pentobarbital was administered as a bolus dose followed by a continuous infusion. The hourly infusion rates ranged from 1 to 4 mg/kg. Adequate sedation was achieved in all six patients. In the four patients who required neuromuscular blocking agents, their use was discontinued after pentobarbital was given. The antihypertensive agents (diazoxide and nitroprusside) required by the two patients receiving extracorporeal membrane oxygenation were also discontinued after pentobarbital administration. Although we continue to use fentanyl and benzodiazepines as first-line drugs for sedation, pentobarbital may be an effective alternative when these agents fail.

Nicardipine: perioperative applications in children.

Nicardipine is the first intravenously administered dihydropyridine calcium channel blocker. Its primary physiological actions include vasodilatation with limited effects on the inotropic and dromotropic function of the myocardium. Several reports have documented its use in adult patients for pharmacological control of blood pressure. We present our experience with the perioperative use of nicardipine in children to treat intraoperative hypertension, as an agent for controlled hypotension during spinal fusion and LeFort I maxillary osteotomies and to treat postoperative hypertension. Dosing regimens and possible applications in paediatric anaesthesia are discussed.

Cardiorespiratory changes in children during laparoscopy.

The authors prospectively examined the cardiorespiratory changes during brief laparoscopy (less than 15 minutes) in children. Intraoperative ventilatory management included a tidal volume of 12 mL/kg, with the rate adjusted to achieve an end-tidal CO2 (PETCO2) of 30 to 35 mm Hg. The initial rate and tidal volume were not changed during the procedure. Baseline measurements of heart rate, blood pressure, peak inflating pressure (PIP), PETCO2, and oxygen saturation were recorded every minute for 5 minutes before the start of the laparoscopic procedure, and every minute during the laparoscopic procedure. Fifty-five patients were enrolled in the study (age range, 1 month to 7 years; weight range, 5.2 to 31 kg). PIP increased from the baseline value of 20 +/- 2.5 to 23 +/- 3.2 cm H2O (P < .01) during laparoscopy. The increase in PIP was 5 or more in six patients, with a maximum of 7. PETCO2 increased from the baseline value of 32 +/- 3.1 to 35 +/- 4.8 mm Hg (P < .01). The PETCO2 returned to baseline within 10 minutes after completion of the laparoscopy. No increase in ventilatory parameters was required during the brief laparoscopic procedure.

Outpatient therapy of iatrogenic drug dependency following prolonged sedation in the pediatric intensive care unit.

The authors present their clinical experience with the oral administration of lorazepam, methadone, and pentobarbital to prevent or treat withdrawal symptoms following prolonged sedation in the PICU patient. The 3 patients presented required prolonged sedation for mechanical ventilation. Different agents were used for sedation in the 3 patients including intravenous fentanyl, midazolam, and pentobarbital. The switch to oral agents must take into consideration the differences in potency, half-life, and oral bioavailability between the agents. The authors discuss the appropriate conversion factors for opioids, benzodiazepines, and barbiturates. The switch to oral administration eliminated the need for intravenous access in the 3 patients and allowed for earlier discharge home. All 3 patients were discharged home on an oral, taper schedule. Such an approach may lead to earlier home discharge thereby improving the patient's quality of life as well as saving health care dollars.

Psychophysiological responses of parents to pediatric critical care stress.

Psychological factors are associated with how parents cope during a child's intensive care hospitalization. However, little is known about the role of physiological-stress responses in parents' coping and adaptation to such situations. This study investigates the relationship between parents' psychophysiological-stress responses, as measured by urine catecholamine excretion, and their coping and activities during a child's intensive care experience. Parents who appraised the situation as one that is amenable to change and who used more problem-focused strategies, such as seeking social support, had lower anxiety and lower catecholamine levels. Further, parents who were more problem focused performed more child care activities during the experience. The results of this study provide information for planning interventions to promote parental coping and adjustment to the child's critical care situation.

Preoperative evaluation of children.

Preoperative evaluation and preparation are directed toward minimizing the intrinsic risks of anesthesia and surgery by having the child in the healthiest possible condition prior to surgery. The pediatrician can contribute to this goal by understanding the effects of general anesthesia on the physiology of children. This knowledge allows an appreciation of the anesthesiologists' concerns regarding underlying diseases, which may seem "stable" (and, therefore, of little present concern to the pediatrician) but which may have grave consequences during anesthesia. The preoperative evaluation is designed to ensure that the child's preoperative needs may be met by providing the anesthesiologist both qualitative and quantitative information regarding the child's state of health and disease. The relationship between the child, parents, and pediatrician places the pediatrician in an ideal position to prepare families for their children's surgical experience.

Disposition and respiratory effects of intrathecal morphine in children.

BACKGROUND: The extent and duration of respiratory depression after opioid administration are poorly defined in infants and children. METHODS: The disposition and respiratory effects of intrathecal morphine were studied in ten patients (ages 4 months-15 yr) after repair of craniofacial defects. Morphine, 0.02 mg/kg, was administered intrathecally before the end of surgery. Postoperatively, we determined the minute ventilation (VE) in response to increasing partial pressure of end-tidal carbon dioxide (PETCO2) during carbon dioxide rebreathing. The slope (VE/PETCO2) and intercept (VE at PETCO2 60 mmHg, VE 60) of the carbon dioxide response curve were calculated at 6, 12, and 18 h after morphine administration. Cerebrospinal fluid (CSF) and blood were analyzed for morphine concentration by radioimmunoassay. RESULTS: Mean VE/PETCO2 decreased from a preoperative value of 35.1 +/- 3.7 to 16.3 +/- 2.8 ml.kg-1 x min-1 x mmHg-1 at 6 h after morphine, and remained depressed to 23.4 +/- 2.9 and 23.5 +/- 3.3 ml.kg-1 x min-1 x mmHg-1 at 12 h and 18 h, respectively, compared to preoperatively). The infants' (n = 3) VE/PETCO2 at 6 h were 21, 4, and 27 ml.kg-1 x min-1 x mmHg-1. Mean VE 60 decreased from 874 +/- 125 to 276 +/- 32 ml x kg-1 x min-1 at 6 h, but then recovered at 12 and 18 h to 491 +/- 68 and 567 +/- 82 ml.kg-1 x min-1, respectively. The infants' VE 60 at 6 h were 350, 142, and 245 ml.kg-1 x min-1. Mean CSF morphine concentration was 2,860 +/- 540 ng/ml at 6 h, and decreased to 640 +/- 220 and 220 +/- 150 ng/ml at 12 and 18 h, respectively. CONCLUSIONS: Intrathecal morphine, 0.02 mg/kg, depressed the ventilatory response to carbon dioxide for up to 18 h concomitant with increased CSF morphine concentrations. Infants (4-12 months of age) did not exhibit greater ventilatory depression than did children (2-15 yr of age).

Ondansetron to prevent emesis following N-acetylcysteine for acetaminophen intoxication.

We present a 17-year-old girl who developed persistent vomiting following acetaminophen overdose. Because of the amount of drug ingested (300 mg/kg acetaminophen) and the four-hour postingestion level (256 micrograms/ml), administration of N-acetylcysteine (NAC) was indicated. Emesis occurred immediately following the first three doses of NAC despite administering the drug by continuous nasogastric drip over one hour. Prior to the next attempt, ondansetron (0.15 mg/kg) was administered intravenously as an antiemetic. Thirty minutes following ondansetron, NAC was tolerated without further emesis. Although several antiemetics may have prevented further emesis, we chose ondansetron since, as a serotonin antagonist, it does not cause extrapyramidal side effects or sedation. In patients with potentially toxic drug ingestions, these side effects may be confused with or mask the adverse effects of the ingested drug, thereby interfering with the ongoing evaluation of the patient. Although not previously administered for this indication, ondansetron has several advantages over other antiemetic agents in the setting of an acute drug ingestion.

Hospitalizations for traumatic injuries among children in Maryland: trends in incidence and severity: 1979 through 1988.

Trends in incidence and severity of hospitalized injury among children aged 0 through 13 years in the state of Maryland from 1979 through 1988 (n = 35,746) were examined using routinely reported hospital discharge data. Hospital discharge rates declined over the study period from 509 per 100,000 population in 1979 to 320 in 1988. There was a decline in incidence trends for both races. However, the decrease in the nonwhite population was smaller than in whites. Analysis of incidence rates for specific Injury Severity Score groups revealed a declining trend in all Injury Severity Score groups, although the mildest group (Injury Severity Score 1 through 4) had the most notable decline of 44% compared with an average decline of 20% in the other severity groups. These data suggest a change in admission practices of mildly injured children as a major cause for the observed overall decline in hospitalization rates. The smaller decrease in the hospitalization rates of non-white children compared with white children requires further study to determine the cause.

Selective release of N-acetylaspartylglutamate from rat optic nerve terminals in vivo.

Glutamate (Glu) and aspartate (Asp) are considered to be the neurotransmitters of the optic pathway in submammalian species, but their roles in mammals is uncertain. Recently, N-acetylaspartylglutamate (NAAG) has been proposed as a neurotransmitter in mammalian optic pathway; however, the release of endogenous NAAG on stimulation of the optic pathway has not been demonstrated. Using an in vivo microdialysis technique, we now report that electrical stimulation of rat optic nerve markedly increased the extracellular concentration of NAAG but not Glu/Asp in superficial superior colliculus where retinal afferents terminate, whereas non-specific stimulation of neurotransmitter release by high potassium or veratridine increased both extracellular Glu/Asp and NAAG concentration in the perfusate. The release of NAAG was dependent on Ca2+ and the presence of optic terminals. We conclude that NAAG is a better candidate as a neurotransmitter of rat optic nerve terminals than Glu/Asp.