Prevention and treatment of intraluminal catheter thrombosis in children hospitalised in a paediatric intensive care unit.

AIM: The aim of the study was to develop and implement a protocol for the prevention and treatment of catheter related intraluminal thrombosis in a paediatric intensive care unit METHODS: A computerised search was carried out on MEDLINE, through PubMed, using the medical subject heading 'central venous catheter', 'central venous access device', 'central venous line' associated with 'occlusion', 'obstruction', 'catheter-related thrombosis', 'critically ill patients' and 'thrombolytic therapy'. References of reviewed articles were also searched for relevant titles as well as non-randomised controlled trials and series of cases when no information of higher level of evidence was available. RESULTS: With the information gathered, a protocol for the prevention and treatment of catheter related intraluminal thrombosis was elaborated and those recommendations that best suit our environment were included. They were agreed upon by a broad panel of professionals working in the Pediatric Intensive Care Unit and the Pharmacy Department. CONCLUSIONS: Due to the variety of options available for the pharmacotherapeutic management of intraluminal catheter thrombosis, one measure to improve the quality of the therapy and to diminish the variability in the prescription could be the implementation of a protocol as described in this paper.

Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis.

OBJECTIVES: The aim of this study was to identify risk points in the different stages of the smart infusion pump implementation process to prioritize improvement measures. METHODS: Failure modes and effects analysis (FMEA) in the pediatric intensive care unit (PICU) of a General and Teaching Hospital. A multidisciplinary team was comprised of two intensive care pediatricians, two clinical pharmacists and the PICU nurse manager. FMEA was carried out before implementing CareFusion infusion smart pumps and eighteen months after to identify risk points during three different stages of the implementation process: creating a drug library; using the technology during clinical practice and analyzing the data stored using Guardrails® CQI v4.1 Event Reporter software. RESULTS: Several actions for improvement were taken. These included carrying out periodical reviews of the drug library, developing support documents, and including a training profile in the system so that alarms set off by real programming errors could be distinguished from those caused by incorrect use of the system. Eighteen months after the implementation, these measures had helped to reduce the likelihood of each risk point occurring and increase the likelihood of their detection. CONCLUSIONS: Carrying out an FMEA made it possible to detect risk points in the use of smart pumps, take action to improve the tool, and adapt it to the PICU. Providing user training and support tools and continuously monitoring results helped to improve the usefulness of the drug library, increased users' compliance with the drug library, and decreased the number of unnecessary alarms.

Rare presentation of shock and acute mesenteric ischaemia secondary to acute adrenal insufficiency in an 11-year-old male.

An 11-year-old Caucasian male with history of abdominal pain, diarrhoea, fatigue, emesis and fever on the previous days presented with dehydratation, shock and acute mesenteric ischaemia. Final diagnosis of Addison's disease was made.

Set of Quality Indicators of Pediatric Intensive Care in Spain: Delphi Method Selection.

INTRODUCTION: This study objective was to identify, select, and define a basic set of quality indicators for pediatric intensive care in Spain. METHODS: (1) Review of the literature to identify quality indicators and their defining elements and (2) selection of indicators by consensus of a group of experts using basic Delphi methodology (2 rounds) and forms distributed by email among experts from the Spanish society of pediatric intensive care. RESULTS: We selected quality indicators according to their relevance and feasibility and the experts' agreement on their incorporation in the final set. We included only those indicators whose assessment was within the highest tertile and greater than or equal to 70% evaluator agreement in the final selection. Starting from an initially proposed set of 136 indicators, 31 experts first selected 43 indicators for inclusion in the second round. Twenty indicators were selected for the final set. This "top 20" set comprised 9 process indicators, 9 of results (especially treatment-associated adverse effects), and 2 indicators of structure. Several of them are classical indicators in intensive care medicine (rates of hospital-acquired infections, pressure ulcers, etc.), whereas others are specifically pediatric (eg, unrestricted parent visitation or training the parents of technology-dependent children). CONCLUSIONS: We reached a consensus on a set of 20 essential quality indicators for pediatric intensive care in Spain. A significant subset reflects the peculiarities of pediatric care. We consider this subset as a starting point for future projects of network collaboration between pediatric intensive care units in Spain.

Implementation of smart pump technology in a paediatric intensive care unit.

Patient safety is a matter of major concern that involves every health professional. Nowadays, emerging technologies such as smart pumps can diminish medication errors as well as standardise and improve clinical practice with the subsequent benefits for patients. The aim of this paper was to describe the smart pump implementation process in a paediatric intensive care unit (PICU) and to present the most relevant infusion-related programming errors that were prevented. This was a comparative study between CareFusion Alaris Guardrails(®) and Hospira MedNet(®) systems, as well as a prospective and intervention study with analytical components carried out in the PICU of Gregorio Marañón General and Teaching Hospital. All intravenous infusions programmed with a pump in the eleven beds of the unit were analyzed. A drug library was developed and subsequently loaded into CareFusion and Hospira pumps that were used during a three month period each. The most suitable system for implementation was selected according to their differences in features and users' acceptance. Data stored in the pumps were analyzed to assess user compliance with the technology, health care setting and type of errors intercepted. The implementation process was carried out with CareFusion systems. Compliance with the technology was 92% and user acceptance was high. Vacation substitution and drug administration periods were significantly associated with a greater number of infusion-related programming errors. High risk drugs were involved in 48% of intercepted errors. Based on these results we can conclude that implementation of smart pumps proved effective in intercepting infusion-related programming errors from reaching patients. User awareness of the importance of programming infusions with the drug library is the key to succeed in the implementation process.

Implementing smart pump technology in a pediatric intensive care unit: a cost-effective approach.

OBJECTIVE: To analyze the cost effectiveness of implementing smart infusion pump technology in a pediatric intensive care unit (PICU). MATERIAL AND METHODS: An observational, prospective, intervention study with analytical components was carried out. A drug library was developed and integrated into the Carefusion Alaris Guardrails® infusion systems. A systematic analysis of all the data stored on the devices during use was performed by the data processing program Guardrails® CQI v4.1 Event Reporter. Intercepted errors were classified in terms of their potential severity and probability of causing an adverse effect (PAE) had they reached the patient. Knowing the estimated cost of a preventable adverse effect (AE), we analyzed costs saved and the profit/cost ratio resulting from the implementation process. RESULTS: Compliance with the drug library was 92% and during the study period 92 infusion-related programming errors were intercepted, leading to a saving of 172,279 euros by preventing AEs. This means that 2.15 euros would be obtained for each euro invested in hiring a pharmacist to implement this technology. DISCUSSION: The high percentage of use of safety software in our study compared to others allowed for the interception of 92 errors. The estimation of the potential impact of these errors is based on clinical judgment. The cost saved might be underestimated because the cost of an AE is usually higher in pediatrics, indirect and intangible costs were not considered and pharmacists involved do not spend the whole day on this task. CONCLUSIONS: Smart pumps have shown to be profitable in a PICU because they have the ability to intercept potentially serious medication errors and reduce costs associated with such errors.

Impact of implementing smart infusion pumps in a pediatric intensive care unit.

PURPOSE: The impact of smart infusion pumps on the interception of errors in the programming of i.v. drug administrations on a pediatric intensive care unit (PICU) is investigated. METHODS: A prospective observational intervention study was conducted in the PICU of a hospital in Madrid, Spain, to estimate the patient safety benefits resulting from the implementation of smart pump technology (Alaris System, CareFusion, San Diego, CA). A systematic analysis of data stored by the devices during the designated study period (January 2010-June 2011) was conducted using the system software (Guardrails CQI Event Reporter, CareFusion). The severity of intercepted errors was independently classified by a group of four clinical pharmacists and a group of four intensive care pediatricians; analyses of intragroup and intergroup agreement in perceptions of severity were performed. RESULTS: During the 17-month study period, the overall rate of user compliance with the safety software was 78%. The use of smart pump technology resulted in the interception of 92 programming errors, 84% of which involved analgesics, antiinfectives, inotropes, and sedatives. About 97% of the errors resulted from user programming of doses or infusion rates above the hard limits defined in the smart pump drug library. The potential consequences of the intercepted errors were considered to be of moderate, serious, or catastrophic severity in 49% of cases. CONCLUSION: The use of smart pumps in a PICU improved patient safety by enabling the interception of infusion programming errors that posed the potential for severe injury to pediatric patients.