Feasibility and indicator outcomes using computerized clinical decision support in pediatric traumatic brain injury anesthesia care.

BACKGROUND: Traumatic brain injury anesthesia care is complex. The use of clinical decision support to improve pediatric trauma care has not been examined. AIMS: The aim of this study was to examine feasibility, reliability, and key performance indicators for traumatic brain injury anesthesia care using clinical decision support. METHODS: Clinical decision support was activated for patients under 19 years undergoing craniotomy for suspected traumatic brain injury. Anesthesia providers were prompted to adhere to process measures via on-screen alerts and notified in real time of abnormal monitor data or laboratory results (unwanted key performance indicator events). Process measures pertained to arterial line placement and blood gas draws, neuromuscular blockade, hypotension, anemia, coagulopathy, hyperglycemia, and intracranial hypertension. Unwanted key performance indicators were: hypotension, hypoxia, hypocarbia, hypercarbia, hypothermia, hyperthermia, anesthetic agent overdose; hypoxemia, coagulopathy, anemia, and hyperglycemia. Anesthesia records, vital signs, and alert logs were reviewed for 39 anesthetic cases (19 without clinical decision support and 20 with clinical decision support). RESULTS: Data from 35 patients aged 11 months to 17 years and 77% males were examined. Clinical decision support reliably identified 39/46 eligible anesthetic cases, with 85% sensitivity and 100% specificity, and was highly sensitive, detecting 89% of monitor key performance indicator events and 100% of reported lab key performance indicator events. There were no false positive alerts. Median event duration was lower in the "with clinical decision support" group for 4/7 key performance indicators. Second insult duration was lower for duration of hypocarbia (by 44%), hypotension (29%), hypothermia (12%), and hyperthermia (15%). CONCLUSION: Use of clinical decision support in pediatric traumatic brain injury anesthesia care is feasible, reliable, and may have the potential to improve key performance indicator outcomes. This observational study suggests the possibility of clinical decision support as a strategy to reduce second insults and improve traumatic brain injury guideline adherence during pediatric anesthesia care.

Comparative prognostic accuracy of sepsis scores for hospital mortality in adults with suspected infection in non-ICU and ICU at an academic public hospital.

BACKGROUND: Sepsis is a global healthcare challenge and reliable tools are needed to identify patients and stratify their risk. Here we compare the prognostic accuracy of the sepsis-related organ failure assessment (SOFA), quick SOFA (qSOFA), systemic inflammatory response syndrome (SIRS), and national early warning system (NEWS) scores for hospital mortality and other outcomes amongst patients with suspected infection at an academic public hospital. MEASUREMENTS AND MAIN RESULTS: 10,981 adult patients with suspected infection hospitalized at a U.S. academic public hospital between 2011-2017 were retrospectively identified. Primary exposures were the maximum SIRS, qSOFA, SOFA, and NEWS scores upon inclusion. Comparative prognostic accuracy for the primary outcome of hospital mortality was assessed using the area under the receiver operating characteristic curve (AUROC). Secondary outcomes included mortality in ICU versus non-ICU settings, ICU transfer, ICU length of stay (LOS) >3 days, and hospital LOS >7 days. Adjusted analyses were performed using a model of baseline risk for hospital mortality. 774 patients (7.1%) died in hospital. Discrimination for hospital mortality was highest for SOFA (AUROC 0.90 [95% CI, 0.89-0.91]), followed by NEWS (AUROC 0.85 [95% CI, 0.84-0.86]), qSOFA (AUROC 0.84 [95% CI, 0.83-0.85]), and SIRS (AUROC 0.79 [95% CI, 0.78-0.81]; p<0.001 for all comparisons). NEWS (AUROC 0.94 [95% CI, 0.93-0.95]) outperformed other scores in predicting ICU transfer (qSOFA AUROC 0.89 [95% CI, 0.87-0.91]; SOFA AUROC, 0.84 [95% CI, 0.82-0.87]; SIRS AUROC 0.81 [95% CI, 0.79-0.83]; p<0.001 for all comparisons). NEWS (AUROC 0.86 [95% CI, 0.85-0.86]) was also superior to other scores in predicting ICU LOS >3 days (SOFA AUROC 0.84 [95% CI, 0.83-0.85; qSOFA AUROC, 0.83 [95% CI, 0.83-0.84]; SIRS AUROC, 0.75 [95% CI, 0.74-0.76]; p<0.002 for all comparisons). CONCLUSIONS: Multivariate prediction scores, such as SOFA and NEWS, had greater prognostic accuracy than qSOFA or SIRS for hospital mortality, ICU transfer, and ICU length of stay. Complex sepsis scores may offer enhanced prognostic performance as compared to simple sepsis scores in inpatient hospital settings where more complex scores can be readily calculated.

Correction: Comparative prognostic accuracy of sepsis scores for hospital mortality in adults with suspected infection in non-ICU and ICU at an academic public hospital.

[This corrects the article DOI: 10.1371/journal.pone.0222563.].

The Pediatric Guideline Adherence and Outcomes (PEGASUS) programme in severe traumatic brain injury: a single-centre hybrid implementation and effectiveness study.

BACKGROUND: As far as we know, there are no tested in-hospital care programmes for paediatric traumatic brain injury. We aimed to assess implementation and effectiveness of the Pediatric Guideline Adherence and Outcomes (PEGASUS) programme in children with severe traumatic brain injury. METHODS: We did a prospective hybrid implementation and effectiveness study at the Harborview Medical Center (Seattle, WA, USA). We included children (aged <18 years) with traumatic brain injury (trauma mechanism and image findings). We assessed service provision, adherence to three key performance indicators, and discharge outcomes associated with the PEGASUS programme. The three key performance indicators were early initiation of enteral (oral or tube feeds) or parenteral nutrition; avoidance of any unwanted hypocarbia (PaCO2 <30 mm Hg) without brain herniation; and maintenance of cerebral perfusion pressure (>40 mm Hg) for 72 h after the diagnosis of severe traumatic brain injury. Poisson regression with robust standard errors was used to estimate the association between adhering to key performance indicators and discharge outcomes. FINDINGS: Between May 1, 2011, and July 1, 2017, 199 children (median age 11·9 years [IQR 3·4-16·1]) participated in the PEGASUS programme, of whom 193 (97%) had severe traumatic brain injury and six (3%) had moderate traumatic brain injury. 105 patients contributed data for all three key performance indicators. Adherence to at least one key performance indicator was achieved by 101 (96%) of 105 participants, and 44 (42%) achieved adherence to all three key performance indicators. Programme participants achieved adherence to the key performance indicators of hypocarbia (76 of 105 [72%]), nutrition (162 of 199 [81%]), and cerebral perfusion pressure (128 of 199 [64%]). Adherence to the nutrition key performance indicator was associated with higher discharge survival (relative risk [RR] 2·70, 95% CI 1·54-4·73) and a more favourable discharge disposition (3·05, 1·52-6·11). Adherence to the cerebral perfusion pressure key performance indicator was also associated with higher discharge survival (RR 1·33, 95% CI 1·12-1·59) and favourable disposition (1·53, 1·19-1·96). Adherence to each additional key performance indicator was associated with higher survival (RR 1·27, 1·12-1·44) and a more favourable discharge disposition (1·46, 1·23-1·72), in a dose-response manner. INTERPRETATION: The multilevel, hospital-wide, high-fidelity PEGASUS programme might benefit children and adolescents admitted to the emergency department with severe traumatic brain injury. Cerebral perfusion pressure, nutrition, and hypocarbia targets are essential components of the PEGASUS programme and are associated with favourable discharge outcomes. FUNDING: National Institutes of Health.

Development and Feasibility of a Real-Time Clinical Decision Support System for Traumatic Brain Injury Anesthesia Care.

BACKGROUND: Real-time clinical decision support (CDS) integrated with anesthesia information management systems (AIMS) can generate point of care reminders to improve quality of care. OBJECTIVE: To develop, implement and evaluate a real-time clinical decision support system for anesthetic management of pediatric traumatic brain injury (TBI) patients undergoing urgent neurosurgery. METHODS: We iteratively developed a CDS system for pediatric TBI patients undergoing urgent neurosurgery. The system automatically detects eligible cases and evidence-based key performance indicators (KPIs). Unwanted clinical events trigger and display real-time messages on the AIMS computer screen. Main outcomes were feasibility of detecting eligible cases and KPIs, and user acceptance. RESULTS: The CDS system was triggered in 22 out of 28 (79%) patients. The sensitivity of detecting continuously sampled KPIs reached 93.8%. For intermittently sampled KPIs, sensitivity and specificity reached 90.9% and 100%, respectively. 88% of providers reported that CDS helped with TBI anesthesia care. CONCLUSIONS: CDS implementation is feasible and acceptable with a high rate of case capture and appropriate generation of alert and guidance messages for TBI anesthesia care.