Impact of integrated clinical decision support systems in the management of pediatric acute kidney injury: a pilot study.

BACKGROUND: Acute kidney injury (AKI) is common but not often recognized. Early recognition and management may improve patient outcomes. METHODS: This is a prospective, nonrandomized study of clinical decision support (CDS) system [combining electronic alert and standardized care pathway (SCP)] to evaluate AKI detection and progression in hospitalized children. The study was done in three phases: pre-, intervention (CDS) and post. During CDS, text-page with AKI stage and link to SCP was sent to patient's contact provider at diagnosis of AKI using creatinine. The SCP provided guidelines on AKI management [AEIOU: Assess cause of AKI, Evaluate drug doses, Intake-Output charting, Optimize volume status, Urine dipstick]. RESULTS: In all, 239 episodes of AKI in 225 patients (97 females, 43.1%) were analyzed. Proportion of patients with decrease in the stage of AKI after onset was 71.4% for CDS vs. 64.4% for pre- and 55% for post-CDS phases (p = 0.3). Documentation of AKI was higher during CDS (74.3% CDS vs. 47.5% pre- and 57.5% post-, p < 0.001). Significantly greater proportion of patients had nephrotoxic medications adjusted, or fluid plan changed during CDS. Patients from CDS phase had higher eGFR at discharge and at follow-up. CONCLUSIONS: AKI remains under-recognized. CDS (electronic alerts and SCP) improve recognition and allow early intervention. This may improve long-term outcomes, but larger studies are needed. IMPACT: Acute kidney injury can cause significant morbidity and mortality. It is under-recognized in children. Clinical decision support can be used to leverage existing data in the electronic health record to improve AKI recognition. This study demonstrates the use of a novel, electronic health record-linked, clinical decision support tool to improve the recognition of AKI and guideline-adherent clinical care.

Therapeutic Plasma Exchange in Children With Thrombocytopenia-Associated Multiple Organ Failure: The Thrombocytopenia-Associated Multiple Organ Failure Network Prospective Experience.

OBJECTIVE: The objective was to compare the resolution of organ dysfunction, 28-day mortality, and biochemical markers in children with thrombocytopenia-associated multiple organ failure who received therapeutic plasma exchange versus no therapeutic plasma exchange. DESIGN: Observational longitudinal cohort study. SETTING: Nine U.S. PICUs. PATIENTS: Eighty-one children with sepsis-induced thrombocytopenia-associated multiple organ failure. INTERVENTIONS: Therapeutic plasma exchange. MEASUREMENTS AND MAIN RESULTS: Adjusted relative risk for 28-day mortality was modeled using standard multivariate regression with propensity score weighting to reduce covariate confounding. Change from baseline Pediatric Logistic Organ Dysfunction scores between therapeutic plasma exchange and no therapeutic plasma exchange differed in temporal pattern during the first week (p = 0.009). By day 4, mean Pediatric Logistic Organ Dysfunction score declined by 7.9 points (95% CI, -10.8 to -5.1) in the therapeutic plasma exchange-treated group compared with no change with no therapeutic plasma exchange. Use of therapeutic plasma exchange was associated with reduced 28-day mortality by multivariate analysis (adjusted relative risk, 0.45; 95% CI, 0.23-0.90; p = 0.02) and by propensity score weighting (adjusted relative risk, 0.46; 95% CI, 0.22-0.97; p = 0.04). CONCLUSIONS: Therapeutic plasma exchange use in thrombocytopenia-associated multiple organ failure was associated with a decrease in organ dysfunction. After accounting for several risk factors, 28-day all-cause mortality was lower in children treated with therapeutic plasma exchange compared with those receiving no therapeutic plasma exchange. A multicenter randomized clinical trial is necessary to determine a causal relationship.

Reductions in invasive device use and care costs after institution of a daily safety checklist in a pediatric critical care unit.

BACKGROUND: In the critical care unit, complexity of care can contribute to both medical errors and increased costs, particularly when clinicians are forced to rely on memory. Checklists can be used to improve safety and reduce cost. A number of omission-related adverse events in 2010 prompted the development of a checklist to reduce the possibility of similar future events. METHODS: The PICU Safety Checklist was implemented in the pediatric ICU (PICU) at Children's Hospitals and Clinics of Minnesota. During a 21-month period, the checklist was used to prompt the care team to address quality and safety items during rounds. The initial checklist was paper, with two subsequent versions being incorporated into the electronic medical record (EMR). RESULTS: The daily safety checklist was successfully implemented in the PICU. Work-flow improvements based on regular multidisciplinary feedback led to more consistent use of the checklist. Improvements on all quality and safety metrics were identified, including invasive device use, medication costs, antibiotic and laboratory test use, and compliance with standards of care. Staff satisfaction rates were > 80% for safety, communication, and collaboration. CONCLUSION: By using a daily safety checklist in the pediatric critical care unit, we improved quality and safety, as well as the collaborative culture among all clinicians. Incorporating the checklist into the EMR improved compliance and accountability, ensuring its application to all patients. Clinicians now often individually address many checklist items outside the formal rounding process, indicating that the checklist content has become part of their usual practice. A successful implementation showing tangible clinical improvements can lead to interest and adoption in other clinical areas within the institution.

Quantifying Discharge Medication Reconciliation Errors at 2 Pediatric Hospitals.

INTRODUCTION: Medication reconciliation errors (MREs) are common and can lead to significant patient harm. Quality improvement efforts to identify and reduce these errors typically rely on resource-intensive chart reviews or adverse event reporting. Quantifying these errors hospital-wide is complicated and rarely done. The purpose of this study is to define a set of 6 MREs that can be easily identified across an entire healthcare organization and report their prevalence at 2 pediatric hospitals. METHODS: An algorithmic analysis of discharge medication lists and confirmation by clinician reviewers was used to find the prevalence of the 6 discharge MREs at 2 pediatric hospitals. These errors represent deviations from the standards for medication instruction completeness, clarity, and safety. The 6 error types are Duplication, Missing Route, Missing Dose, Missing Frequency, Unlisted Medication, and See Instructions errors. RESULTS: This study analyzed 67,339 discharge medications and detected MREs commonly at both hospitals. For Institution A, a total of 4,234 errors were identified, with 29.9% of discharges containing at least one error and an average of 0.7 errors per discharge. For Institution B, a total of 5,942 errors were identified, with 42.2% of discharges containing at least 1 error and an average of 1.6 errors per discharge. The most common error types were Duplication and See Instructions errors. CONCLUSION: The presented method shows these MREs to be a common finding in pediatric care. This work offers a tool to strengthen hospital-wide quality improvement efforts to reduce pediatric medication errors.

Level of sedation with nitrous oxide for pediatric medical procedures.

BACKGROUND: Nitrous oxide (N(2)O) delivered at a concentration <50% is accepted as a minimal sedation drug by both the American Society of Anesthesiologists and the American Academy of Pediatrics. The expected level of sedation at an N(2)O concentration >50% is less clear. METHODS: We conducted a retrospective chart review for all children receiving N(2)O for procedural sedation at Children's Hospitals and Clinics of Minnesota. Patient age, maximal N(2)O concentration, duration of N(2)O administration, completion of procedure, and adverse events were recorded. Level of sedation was assessed on a 0 to 6 scale. RESULTS: N(2)O was administered on 1858 occasions to 1585 patients younger than 18 years. Most administrations (91.3%) were N(2)O concentration >50%. Level of sedation scores were as follows: 6 (inadequate) = 1.3%; 5 (minimal) = 94.3%; and 4 (drowsy) = 4.3%; no patient reached a sedation score <4. Fifty-nine patients (3.3%) had adverse events of which 6 (0.3%) were atypical. There was no difference between N(2)O < or =50% and N(2)O >50% in the level of sedation or number of adverse events. More children < or =2 years (7.4%) achieved a sedation level of 4 than those older than 2 years (4%), but they experienced a similar rate of adverse events. There was no difference in the level of sedation by duration of N(2)O administration. Inadequately sedated patients were younger than the remainder of the group. Most procedures (94.1%) were completed with the patient calm and still. CONCLUSIONS: A significant number of children remain minimally sedated while receiving N(2)O at concentrations >50% via nasal hood using a system designed to titrate N(2)O concentration from 0% to 70%. Adverse event rates of patients receiving >50% N(2)O in this manner are similar to rates reported in large studies of 50% N(2)O administration.

Core drug-drug interaction alerts for inclusion in pediatric electronic health records with computerized prescriber order entry.

OBJECTIVE: The study aims to develop a core set of pediatric drug-drug interaction (DDI) pairs for which electronic alerts should be presented to prescribers during the ordering process. METHODS: A clinical decision support working group composed of Children's Hospital Association (CHA) members was developed. CHA Pharmacists and Chief Medical Information Officers participated. RESULTS: Consensus was reached on a core set of 19 DDI pairs that should be presented to pediatric prescribers during the order process. CONCLUSIONS: We have provided a core list of 19 high value drug pairs for electronic drug-drug interaction alerts to be recommended for inclusion as high value alerts in prescriber order entry software used with a pediatric patient population. We believe this list represents the most important pediatric drug interactions for practical implementation within computerized prescriber order entry systems.

Acute brain herniation from lead toxicity.

A 4-year-old black boy was admitted to the hospital with vomiting, low-grade fever, and dehydration that were thought to be caused by viral gastroenteritis. He proceeded over the next 12 hours to rapidly deteriorate with brain herniation leading to brain death. The ultimate cause of death was found to be acute lead intoxication from a swallowed foreign body.