Reducing Time to Postintubation Sedation in a Pediatric Emergency Department.

BACKGROUND AND OBJECTIVE: Inadequate postintubation sedation (PIS) can lead to unplanned extubations, conscious paralysis, and overall unsafe care of patients. From 2018 to 2020, we realized at our hospital that ∼25% of children received sedation in an adequate time frame in the pediatric emergency department, with 2 unplanned dislodgements of the endotracheal tube. Our objective was to reduce time to initiating PIS from a mean of 39 minutes to less than 15 minutes in our pediatric emergency department by September 2021. METHODS: A multidisciplinary team was formed in March 2020 to develop a key driver diagram and a protocol to standardize PIS. Baseline data were obtained from December 2017 through March 2020. The primary measure was time from intubation to administration of first sedation medication. Plan-do-study-act cycles informed interventions for protocol development, awareness, education, order set development, and PIS checklist. The secondary measure was unplanned extubations and the balancing measure was PIS-related hypotension requiring pressors. An X-bar and S chart were used to analyze data. RESULTS: Protocol implementation was associated with decrease in mean time to PIS from 39 minutes to 21 minutes. Following educational interventions, order set implementation, and the addition of PIS plan to the intubation checklist, there was a decrease in mean time to PIS to 13 minutes, which was sustained for 9 months without any observed episodes of PIS-related hypotension or unplanned extubations. CONCLUSIONS: Quality improvement methodology led to a sustained reduction in time to initiation of PIS in a pediatric emergency department.

A Comparison of Teleburn to In-Person Consultation of Pediatric Patients in a Children's Emergency Department.

Pediatric burn care is an essential component of emergency care and there are disparities in access to regional burn centers. Teleburn is a tool that enables providers without a certified burn center to provide photos of a burn to experts and receive recommendations. The purpose of this study is to evaluate the effectiveness of a Teleburn system to the in-person consultation regarding burn infection rate, clinic follow-up rate, postburn admission rate, and 72-h bounce back rate. Data were collected from December 2019 to March 2022 through the electronic medical record. A total of 416 patient encounters that met the criteria were analyzed. A non-inferiority study was designed comparing proportional outcomes of Teleburn initial visits to emergency department visits regarding burn infection rate, clinic follow-up rate, postburn admission rate, and 72-h bounce back rate. The data were compared with a difference of greater than 10% being considered inferior. No differences were identified in rates of readmission-1.67% difference (95% CI -27%< x < 23.8%) and return within 72 h-0.7% difference (-18.4%< x < 19.7%). Teleburn patients were 12.6% less likely to follow-up (2.7%< x < 22.40%). Only one infection was identified, which was insufficient to conclude non-inferiority. While convenient, Teleburn consult could not be demonstrated to be non-inferior to in-person consultation. No differences in infection rates were identified, and differences in readmission and return were clinically insignificant. This study demonstrates that Teleburn may be effective and feasible for regional burn centers if follow-up can be improved.

A rare cause of posterior reversible encephalopathy syndrome: Acute lymphoblastic leukemia.

Key Clinical Message: The presentation of posterior reversible encephalopathy syndrome (PRES) as the initial presenting sign of acute lymphoblastic leukemia is unusual, as PRES is more often a complication of therapy. This case highlights the importance of maintaining a broad differential diagnosis for pediatric hypertension and its complications. Abstract: A 6-year-old male presented with a seizure-like episode. Evaluation revealed hypertension and brain imaging showed findings consistent with posterior reversible encephalopathy syndrome. Complete blood count showed lymphoblasts, and the cause of his hypertension was determined to be renal infiltration of leukemia cells due to B-cell acute lymphoblastic leukemia.