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Pedersen BBB, Lauridsen KG, Langsted ST, Løfgren B. Organization and training for pediatric cardiac arrest in Danish hospitals: A nationwide cross-sectional study. Resusc Plus 2024; 17:100555. [PMID: 38586865 PMCID: PMC10995645 DOI: 10.1016/j.resplu.2024.100555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024] Open
Abstract
Background Improving survival from pediatric cardiac arrest requires a well-functioning system of care with appropriately trained healthcare providers and designated cardiac arrest teams. This study aimed to describe the current organization and training for pediatric cardiac arrest in Denmark. Methods We performed a nationwide cross-sectional study. A questionnaire was distributed to all hospitals in Denmark with a pediatric department. The survey included questions about receiving patients with out-of-hospital cardiac arrest, protocols for extracorporeal life support, cardiac arrest team compositions, and training. Results We obtained responses from 17 of 19 hospitals with a pediatric department. In total, 76% of hospitals received patients with pediatric out-of-hospital cardiac arrest and 35% of hospitals had a protocol for extracorporeal life support. None of the hospitals had identical cardiac arrest team member compositions. The total number of team members ranged from 4-10, with a median of 8 members (IQR 7;9). In 84% of hospitals a specialized course in pediatric resuscitation was implemented and in 5% of hospitals, the specialized course was for the entire cardiac arrest team. Only few hospitals had training in laryngeal mask (6%) and intubation (29%) for pediatric cardiac arrest and none of them were trained in extracorporeal life support. Conclusion We found high variability in the composition of the pediatric cardiac arrest teams and training across the surveyed Danish hospitals. Many hospitals lack training in important pediatric resuscitation skills. Although many hospitals receive pediatric patients after out-of-hospital cardiac arrest, only few have protocols for transfer for extracorporeal life support.
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Affiliation(s)
- Bea Brix B. Pedersen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
- Department of Medicine, Randers Regional Hospital, Denmark
| | - Kasper G. Lauridsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
- Department of Medicine, Randers Regional Hospital, Denmark
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, USA
| | - Sandra Thun Langsted
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
- Department of Emergency Medicine, Randers Regional Hospital, Denmark
| | - Bo Løfgren
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
- Department of Medicine, Randers Regional Hospital, Denmark
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Al-Harbi S. Impact of Rapid Response Teams on Pediatric Care: An Interrupted Time Series Analysis of Unplanned PICU Admissions and Cardiac Arrests. Healthcare (Basel) 2024; 12:518. [PMID: 38470629 PMCID: PMC10931051 DOI: 10.3390/healthcare12050518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/12/2024] [Accepted: 02/18/2024] [Indexed: 03/14/2024] Open
Abstract
Pediatric rapid response teams (RRTs) are expected to significantly lower pediatric mortality in healthcare settings. This study evaluates RRTs' effectiveness in decreasing cardiac arrests and unexpected Pediatric Intensive Care Unit (PICU) admissions. A quasi-experimental study (2014-2017) at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, involved 3261 pediatric inpatients, split into pre-intervention (1604) and post-intervention (1657) groups. Baseline pediatric warning scores and monthly data on admissions, transfers, arrests, and mortality were analyzed pre- and post-intervention. Statistical methods including bootstrapping, segmented regression, and a Zero-Inflation Poisson model were employed to ensure a comprehensive evaluation of the intervention's impact. RRT was activated 471 times, primarily for respiratory distress (29.30%), sepsis (22.30%), clinical anxiety (13.80%), and hematological abnormalities (6.7%). Family concerns triggered 0.1% of activations. Post-RRT implementation, unplanned PICU admissions significantly reduced (RR = 0.552, 95% CI 0.485-0.628, p < 0.0001), and non-ICU cardiac arrests were eliminated (RR = 0). Patient care improvement was notable, with a -9.61 coefficient for PICU admissions (95% CI: -12.65 to -6.57, p < 0.001) and a -1.641 coefficient for non-ICU cardiac arrests (95% CI: -2.22 to -1.06, p < 0.001). Sensitivity analysis showed mixed results for PICU admissions, while zero-inflation Poisson analysis confirmed a reduction in non-ICU arrests. The deployment of pediatric RRTs is associated with fewer unexpected PICU admissions and non-ICU cardiopulmonary arrests, indicating improved PICU management. Further research using robust scientific methods is necessary to conclusively determine RRTs' clinical benefits.
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Affiliation(s)
- Samah Al-Harbi
- Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia;
- Department of Pediatrics, King Abdulaziz University Hospital, Jeddah 22252, Saudi Arabia
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Liang H, Carey KA, Jani P, Gilbert ER, Afshar M, Sanchez-Pinto LN, Churpek MM, Mayampurath A. Association between mortality and critical events within 48 hours of transfer to the pediatric intensive care unit. Front Pediatr 2023; 11:1284672. [PMID: 38188917 PMCID: PMC10768058 DOI: 10.3389/fped.2023.1284672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024] Open
Abstract
Introduction Critical deterioration in hospitalized children, defined as ward to pediatric intensive care unit (PICU) transfer followed by mechanical ventilation (MV) or vasoactive infusion (VI) within 12 h, has been used as a primary metric to evaluate the effectiveness of clinical interventions or quality improvement initiatives. We explore the association between critical events (CEs), i.e., MV or VI events, within the first 48 h of PICU transfer from the ward or emergency department (ED) and in-hospital mortality. Methods We conducted a retrospective study of a cohort of PICU transfers from the ward or the ED at two tertiary-care academic hospitals. We determined the association between mortality and occurrence of CEs within 48 h of PICU transfer after adjusting for age, gender, hospital, and prior comorbidities. Results Experiencing a CE within 48 h of PICU transfer was associated with an increased risk of mortality [OR 12.40 (95% CI: 8.12-19.23, P < 0.05)]. The increased risk of mortality was highest in the first 12 h [OR 11.32 (95% CI: 7.51-17.15, P < 0.05)] but persisted in the 12-48 h time interval [OR 2.84 (95% CI: 1.40-5.22, P < 0.05)]. Varying levels of risk were observed when considering ED or ward transfers only, when considering different age groups, and when considering individual 12-h time intervals. Discussion We demonstrate that occurrence of a CE within 48 h of PICU transfer was associated with mortality after adjusting for confounders. Studies focusing on the impact of quality improvement efforts may benefit from using CEs within 48 h of PICU transfer as an additional evaluation metric, provided these events could have been influenced by the initiative.
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Affiliation(s)
- Huan Liang
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
| | - Kyle A. Carey
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Priti Jani
- Department of Pediatrics, University of Chicago, Chicago, IL, United States
| | - Emily R. Gilbert
- Department of Medicine, Loyola University Medical Center, Maywood, IL, United States
| | - Majid Afshar
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - L. Nelson Sanchez-Pinto
- Department of Pediatrics (Critical Care), Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
| | - Matthew M. Churpek
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Anoop Mayampurath
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, WI, United States
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
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Chung SP, Sohn Y, Lee J, Cho Y, Cha KC, Heo JS, Kim ARE, Kim JG, Kim HS, Shin H, Ahn C, Woo HG, Lee BK, Jang YS, Choi YH, Hwang SO. Expert opinion on evidence after the 2020 Korean Cardiopulmonary Resuscitation Guidelines: a secondary publication. Clin Exp Emerg Med 2023; 10:382-392. [PMID: 37620035 PMCID: PMC10790069 DOI: 10.15441/ceem.23.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 08/26/2023] Open
Abstract
Considerable evidence has been published since the 2020 Korean Cardiopulmonary Resuscitation Guidelines were reported. The International Liaison Committee on Resuscitation (ILCOR) also publishes the Consensus on CPR and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) summary annually. This review provides expert opinions by reviewing the recent evidence on CPR and ILCOR treatment recommendations. The authors reviewed the CoSTR summary published by ILCOR in 2021 and 2022. PICO (patient, intervention, comparison, outcome) questions for each topic were reviewed using a systemic or scoping review methodology. Two experts were appointed for each question and reviewed the topic independently. Topics suggested by the reviewers for revision or additional description of the guidelines were discussed at a consensus conference. Forty-three questions were reviewed, including 15 on basic life support, seven on advanced life support, two on pediatric life support, 11 on neonatal life support, six on education and teams, one on first aid, and one related to COVID-19. Finally, the current Korean CPR Guideline was maintained for 28 questions, and expert opinions were suggested for 15 questions.
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Affiliation(s)
- Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Youdong Sohn
- Department of Emergency Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Jisook Lee
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Youngsuk Cho
- Department of Emergency Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Kyoung-Chul Cha
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ju Sun Heo
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
- Institute of Nano, Regeneration, Reconstruction, Korea University, Seoul, Korea
| | - Ai-Rhan Ellen Kim
- Department of Pediatrics, CHA University Ilsan Medical Center, Goyang, Korea
| | - Jae Guk Kim
- Department of Emergency Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hyungoo Shin
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Ho Geol Woo
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Yong Soo Jang
- Department of Emergency Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Yu Hyeon Choi
- Department of Pediatrics, Seoul Medical Center, Seoul, Korea
| | - Sung Oh Hwang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - on behalf of the Guideline Committee of the Korean Association of Cardiopulmonary Resuscitation (KACPR)
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
- Institute of Nano, Regeneration, Reconstruction, Korea University, Seoul, Korea
- Department of Pediatrics, CHA University Ilsan Medical Center, Goyang, Korea
- Department of Emergency Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea
- Department of Emergency Medicine, Chonnam National University Medical School, Gwangju, Korea
- Department of Pediatrics, Seoul Medical Center, Seoul, Korea
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Kritz EM, Thomas JK, Alawa NS, Hadad EB, Guffey DM, Bavare AC. Rapid response events with multiple triggers are associated with poor outcomes in children. Front Pediatr 2023; 11:1208873. [PMID: 37388290 PMCID: PMC10303937 DOI: 10.3389/fped.2023.1208873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 05/24/2023] [Indexed: 07/01/2023] Open
Abstract
Objective We describe the characteristics and outcomes of pediatric rapid response team (RRT) events within a single institution, categorized by reason for RRT activation (RRT triggers). We hypothesized that events with multiple triggers are associated with worse outcomes. Patients and Methods Retrospective 3-year study at a high-volume tertiary academic pediatric hospital. We included all patients with index RRT events during the study period. Results Association of patient and RRT event characteristics with outcomes including transfers to ICU, need for advanced cardiopulmonary support, ICU and hospital length of stay (LOS), and mortality were studied. We reviewed 2,267 RRT events from 2,088 patients. Most (59%) were males with a median age of 2 years and 57% had complex chronic conditions. RRT triggers were: respiratory (36%) and multiple (35%). Transfer to the ICU occurred after 1,468 events (70%). Median hospital and ICU LOS were 11 and 1 days. Need for advanced cardiopulmonary support was noted in 291 events (14%). Overall mortality was 85 (4.1%), with 61 (2.9%) of patients having cardiopulmonary arrest (CPA). Multiple RRT trigger events were associated with transfer to the ICU (559 events; OR 1.48; p < 0.001), need for advanced cardiopulmonary support (134 events; OR 1.68; p < 0.001), CPA (34 events; OR 2.36; p = 0.001), and longer ICU LOS (2 vs. 1 days; p < 0.001). All categories of triggers have lower odds of need for advanced cardiopulmonary support than multiple triggers (OR 1.73; p < 0.001). Conclusions RRT events with multiple triggers were associated with cardiopulmonary arrest, transfer to ICU, need for cardiopulmonary support, and longer ICU LOS. Knowledge of these associations can guide clinical decisions, care planning, and resource allocation.
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Affiliation(s)
- Erin M. Kritz
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Jenilea K. Thomas
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Nawara S. Alawa
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Elit B. Hadad
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
| | - Danielle M. Guffey
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
| | - Aarti C. Bavare
- Department of Pediatric Critical Care, Baylor College of Medicine, Houston, TX, United States
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX, United States
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Kuehn SE, Melvin JE, Creech PS, Fitch J, Noritz G, Perry MF, Stewart C, Bode RS. Reduction of Very Rapid Emergency Transfers to the Pediatric Intensive Care Unit. Pediatr Qual Saf 2023; 8:e645. [PMID: 38571737 PMCID: PMC10990303 DOI: 10.1097/pq9.0000000000000645] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 03/07/2023] [Indexed: 04/05/2024] Open
Abstract
Introduction Emergency transfers are associated with increased inpatient pediatric mortality. Therefore, interventions to improve system-level situational awareness were utilized to decrease a subset of emergency transfers that occurred within four hours of admission to an inpatient medical-surgical unit called very rapid emergency transfers (VRET). Specifically, we aimed to increase the days between VRET from non-ICU inpatient units from every 10 days to every 25 days over 1 year. Methods Using the Model for Improvement, we developed an interdisciplinary team to reduce VRET. The key drivers targeted were the admission process from the emergency department and ambulatory clinics, sepsis recognition and communication, and expansion of our situational awareness framework. Days between VRET defined the primary outcome metric for this improvement project. Results After six months of interventions, our baseline improved from a VRET every 10 days to every 79 days, followed by another shift to 177 days, which we sustained for 3 years peaking at 468 days between events. Conclusion Interventions targeting multiple admission sources to improve early recognition and communication of potential clinical deterioration effectively reduced and nearly eliminated VRET at our organization.
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Affiliation(s)
- Stacy E. Kuehn
- From the Center for Clinical Excellence Columbus, Nationwide Children’s Hospital, Ohio
| | - Jennifer E. Melvin
- From the Center for Clinical Excellence Columbus, Nationwide Children’s Hospital, Ohio
| | - Pamela S. Creech
- From the Center for Clinical Excellence Columbus, Nationwide Children’s Hospital, Ohio
| | - Jill Fitch
- From the Center for Clinical Excellence Columbus, Nationwide Children’s Hospital, Ohio
| | - Garey Noritz
- From the Center for Clinical Excellence Columbus, Nationwide Children’s Hospital, Ohio
| | - Michael F. Perry
- From the Center for Clinical Excellence Columbus, Nationwide Children’s Hospital, Ohio
| | - Claire Stewart
- From the Center for Clinical Excellence Columbus, Nationwide Children’s Hospital, Ohio
| | - Ryan S. Bode
- From the Center for Clinical Excellence Columbus, Nationwide Children’s Hospital, Ohio
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Greenberg JM, Schmidt A, Chang TP, Rake A. Qualitative Study on Safe and Effective Handover Information during a Rapid Response Team Encounter. Pediatr Qual Saf 2023; 8:e650. [PMID: 38571734 PMCID: PMC10990382 DOI: 10.1097/pq9.0000000000000650] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 04/01/2023] [Indexed: 04/05/2024] Open
Abstract
Introduction A rapid response team (RRT) evaluates and manages patients at risk of clinical deterioration. There is limited literature on the structure of the rapid response encounter from the floor to the intensive care unit team. We aimed to define this encounter and examine provider experiences to elucidate what information healthcare staff need to safely manage patients during an RRT evaluation. Methods This phenomenological qualitative study included 6 focus groups (3 in-person and 3 virtually) organized by provider type (nurses, residents, fellows, attendings), which took place until thematic saturation was reached. Two authors inductively coded transcripts and used a quota sampling strategy to ensure that the focus groups represented key stakeholders. Transcripts were then analyzed to identify themes that providers believe influence the RRT's quality, efficacy, and efficiency and their ability to manage and treat the acutely decompensating pediatric patient on the floor. Results Transcript coding yielded 38 factors organized into 8 themes. These themes are a summary statement or recap, closed-loop communication, interpersonal communication, preparation, duration, emotional validation, contingency planning, and role definition. Conclusions The principal themes of utmost importance at our institution during an RRT encounter are preparation, a brief and concise handoff from the floor team, and a summary statement from the intensive care unit team with contingency planning at the end of the encounter. Our data suggest that some standardization may be beneficial during the handoff.
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Affiliation(s)
- Justin M. Greenberg
- From the Department of Anesthesia and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, Calif
| | - Anita Schmidt
- Department of Emergency Medicine, Children’s Hospital Los Angeles, Los Angeles, Calif
| | - Todd P. Chang
- Department of Emergency Medicine, Children’s Hospital Los Angeles, Los Angeles, Calif
| | - Alyssa Rake
- From the Department of Anesthesia and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, Calif
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Rust LOH, Gorham TJ, Bambach S, Bode RS, Maa T, Hoffman JM, Rust SW. The Deterioration Risk Index: Developing and Piloting a Machine Learning Algorithm to Reduce Pediatric Inpatient Deterioration. Pediatr Crit Care Med 2023; 24:322-333. [PMID: 36735282 DOI: 10.1097/pcc.0000000000003186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Develop and deploy a disease cohort-based machine learning algorithm for timely identification of hospitalized pediatric patients at risk for clinical deterioration that outperforms our existing situational awareness program. DESIGN Retrospective cohort study. SETTING Nationwide Children's Hospital, a freestanding, quaternary-care, academic children's hospital in Columbus, OH. PATIENTS All patients admitted to inpatient units participating in the preexisting situational awareness program from October 20, 2015, to December 31, 2019, excluding patients over 18 years old at admission and those with a neonatal ICU stay during their hospitalization. INTERVENTIONS We developed separate algorithms for cardiac, malignancy, and general cohorts via lasso-regularized logistic regression. Candidate model predictors included vital signs, supplemental oxygen, nursing assessments, early warning scores, diagnoses, lab results, and situational awareness criteria. Model performance was characterized in clinical terms and compared with our previous situational awareness program based on a novel retrospective validation approach. Simulations with frontline staff, prior to clinical implementation, informed user experience and refined interdisciplinary workflows. Model implementation was piloted on cardiology and hospital medicine units in early 2021. MEASUREMENTS AND MAIN RESULTS The Deterioration Risk Index (DRI) was 2.4 times as sensitive as our existing situational awareness program (sensitivities of 53% and 22%, respectively; p < 0.001) and required 2.3 times fewer alarms per detected event (121 DRI alarms per detected event vs 276 for existing program). Notable improvements were a four-fold sensitivity gain for the cardiac diagnostic cohort (73% vs 18%; p < 0.001) and a three-fold gain (81% vs 27%; p < 0.001) for the malignancy diagnostic cohort. Postimplementation pilot results over 18 months revealed a 77% reduction in deterioration events (three events observed vs 13.1 expected, p = 0.001). CONCLUSIONS The etiology of pediatric inpatient deterioration requires acknowledgement of the unique pathophysiology among cardiology and oncology patients. Selection and weighting of diverse candidate risk factors via machine learning can produce a more sensitive early warning system for clinical deterioration. Leveraging preexisting situational awareness platforms and accounting for operational impacts of model implementation are key aspects to successful bedside translation.
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Affiliation(s)
- Laura O H Rust
- Division of Clinical Informatics, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Information Technology Research & Innovation, Nationwide Children's Hospital, Columbus, OH
- Division of Hospital Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
- Division of Pediatric Critical Care, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Tyler J Gorham
- Information Technology Research & Innovation, Nationwide Children's Hospital, Columbus, OH
| | - Sven Bambach
- Information Technology Research & Innovation, Nationwide Children's Hospital, Columbus, OH
| | - Ryan S Bode
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Division of Hospital Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Tensing Maa
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Division of Pediatric Critical Care, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jeffrey M Hoffman
- Division of Clinical Informatics, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
- Division of Emergency Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
- Information Technology Research & Innovation, Nationwide Children's Hospital, Columbus, OH
- Division of Hospital Pediatrics, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
- Division of Pediatric Critical Care, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Steven W Rust
- Information Technology Research & Innovation, Nationwide Children's Hospital, Columbus, OH
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Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Phil Chung S, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de Caen AR, Deakin CD, Djärv T, Donnino MW, Douma MJ, Duff JP, Dunne CL, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Finn J, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman M, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin YJ, Lockey AS, Maconochie IK, Madar J, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Morgan P, Morrison LJ, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, O'Neill BJ, Gene Ong YK, Orkin AM, Paiva EF, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Sugiura T, Tijssen JA, Trevisanuto D, Van de Voorde P, Wang TL, Weiner GM, Wyllie JP, Yang CW, Yeung J, Nolan JP, Berg KM. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Pediatrics 2023; 151:189896. [PMID: 36325925 DOI: 10.1542/peds.2022-060463] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.
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10
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Choi J, Choi AY, Park E, Moon S, Son MH, Cho J. Trends in Incidences and Survival Rates in Pediatric In-Hospital Cardiopulmonary Resuscitation: A Korean Population-Based Study. J Am Heart Assoc 2023; 12:e028171. [PMID: 36695322 PMCID: PMC9973657 DOI: 10.1161/jaha.122.028171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Although the outcome of cardiopulmonary resuscitation (CPR) is still unsatisfactory, there are few studies about temporal trends of in-hospital CPR incidence and mortality. We aimed to evaluate nationwide trends of in-hospital CPR incidence and its associated risk factors and mortality in pediatric patients using a database of the Korean National Health Insurance between 2012 and 2018. Methods and Results We excluded neonates and neonatal intensive care unit admissions. Incidence of in-hospital pediatric CPR was 0.58 per 1000 admissions (3165 CPR/5 429 471 admissions), and the associated mortality was 50.4%. Change in CPR incidence according to year was not significant in an adjusted analysis (P=0.234). However, CPR mortality increased significantly by 6.6% every year in an adjusted analysis (P<0.001). Hospitals supporting pediatric critical care showed 37.7% lower odds of CPR incidence (P<0.001) and 27.5% lower odds of mortality compared with other hospitals in the adjusted analysis (P<0.001), and they did not show an increase in mortality (P for trend=0.882). Conclusions Temporal trends of in-hospital CPR mortality worsened in Korea, and the trends differed according to subgroups. Study results highlight the need for ongoing evaluation of CPR trends and for further CPR outcome improvement among hospitalized children.
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Affiliation(s)
- Jaeyoung Choi
- Department of Critical Care MedicineSamsung Medical Center, Sungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Ah Young Choi
- Department of PediatricsChungnam National University HospitalDaejeonRepublic of Korea
| | - Esther Park
- Department of PediatricsJeonbuk National University Children’s HospitalJeonjuRepublic of Korea
| | - Suhyeon Moon
- Research Institute for Future MedicineSamsung Medical CenterSeoulRepublic of Korea
| | - Meong Hi Son
- Department of PediatricsSamsung Medical Center, Sungkyunkwan University School of MedicineSeoulRepublic of Korea
| | - Joongbum Cho
- Department of Critical Care MedicineSamsung Medical Center, Sungkyunkwan University School of MedicineSeoulRepublic of Korea
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11
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Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Chung SP, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de Caen AR, Deakin CD, Djärv T, Donnino MW, Douma MJ, Duff JP, Dunne CL, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Finn J, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman M, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin YJ, Lockey AS, Maconochie IK, Madar RJ, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Morgan P, Morrison LJ, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, O'Neill BJ, Ong YKG, Orkin AM, Paiva EF, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Sugiura T, Tijssen JA, Trevisanuto D, Van de Voorde P, Wang TL, Weiner GM, Wyllie JP, Yang CW, Yeung J, Nolan JP, Berg KM, Cartledge S, Dawson JA, Elgohary MM, Ersdal HL, Finan E, Flaatten HI, Flores GE, Fuerch J, Garg R, Gately C, Goh M, Halamek LP, Handley AJ, Hatanaka T, Hoover A, Issa M, Johnson S, Kamlin CO, Ko YC, Kule A, Leone TA, MacKenzie E, Macneil F, Montgomery W, O’Dochartaigh D, Ohshimo S, Palazzo FS, Picard C, Quek BH, Raitt J, Ramaswamy VV, Scapigliati A, Shah BA, Stewart C, Strand ML, Szyld E, Thio M, Topjian AA, Udaeta E, Vaillancourt C, Wetsch WA, Wigginton J, Yamada NK, Yao S, Zace D, Zelop CM. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2022; 146:e483-e557. [PMID: 36325905 DOI: 10.1161/cir.0000000000001095] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.
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12
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Chalam JN, Noble J, DeLaroche AM, Ehrman RR, Cashen K. Characteristics of Adult Rapid Response Events in a Freestanding Children's Hospital. Hosp Pediatr 2022; 12:1058-1065. [PMID: 36377402 DOI: 10.1542/hpeds.2022-006748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe nonhospitalized adult rapid response events (adult RREs) in a freestanding children's hospital and examine the relationship between various demographic and clinical factors with the final patient disposition. METHODS We retrospectively reviewed records for nonhospitalized patients ≥18 years of age from events that occurred in a freestanding pediatric hospital between January 2011 through December 2020. We examined the relationship between adult RREs and patient demographic information, medical history, interventions, and patient disposition following an adult RRE. RESULTS Four hundred twenty-nine events met inclusion criteria for analysis. Most events (69%) occurred in females, 49% of events occurred in family members of patients, and 47% occurred on inpatient floor and ICU areas. The most common presenting complaint was syncope or dizziness (36%). Delivery of bad news or grief response was associated with 14% of adult RREs. Overall, 46% (n = 196) of patients were transferred to the pediatric emergency department (ED). Patients requiring acute intervention or with cardiac or neurologic past medical histories were more likely to be transferred to the pediatric ED. Acute advanced cardiac life support interventions were infrequent but, of the patients taken to the pediatric ED, 1 died, and 3 were admitted to the ICU. CONCLUSIONS Adult RREs are common in freestanding children's hospitals and, although rare, some patients required critical care. Expertise in adult critical care management should be available to the rapid response team and additional training for the pediatric rapid response team in caring for adult nonpatients may be warranted.
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Affiliation(s)
- Jennifer N Chalam
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Jennifer Noble
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.,Central Michigan University School of Medicine, Mount Pleasant, Michigan
| | - Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.,Central Michigan University School of Medicine, Mount Pleasant, Michigan
| | - Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit Medical Center, Sinai-Grace Hospital, Detroit, Michigan
| | - Katherine Cashen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University Children's Hospital, Duke University School of Medicine, Durham, North Carolina
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13
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Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Phil Chung S, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de Caen AR, Deakin CD, Djärv T, Donnino MW, Douma MJ, Duff JP, Dunne CL, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Finn J, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman M, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin YJ, Lockey AS, Maconochie IK, Madar RJ, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Morgan P, Morrison LJ, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, O'Neill BJ, Gene Ong YK, Orkin AM, Paiva EF, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Sugiura T, Tijssen JA, Trevisanuto D, Van de Voorde P, Wang TL, Weiner GM, Wyllie JP, Yang CW, Yeung J, Nolan JP, Berg KM, Cartledge S, Dawson JA, Elgohary MM, Ersdal HL, Finan E, Flaatten HI, Flores GE, Fuerch J, Garg R, Gately C, Goh M, Halamek LP, Handley AJ, Hatanaka T, Hoover A, Issa M, Johnson S, Kamlin CO, Ko YC, Kule A, Leone TA, MacKenzie E, Macneil F, Montgomery W, O’Dochartaigh D, Ohshimo S, Stefano Palazzo F, Picard C, Quek BH, Raitt J, Ramaswamy VV, Scapigliati A, Shah BA, Stewart C, Strand ML, Szyld E, Thio M, Topjian AA, Udaeta E, Vaillancourt C, Wetsch WA, Wigginton J, Yamada NK, Yao S, Zace D, Zelop CM. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation 2022; 181:208-288. [PMID: 36336195 DOI: 10.1016/j.resuscitation.2022.10.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.
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14
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Mobilization of Children with External Ventricular Drains: A Retrospective Cohort Study. CHILDREN 2022; 9:children9111777. [DOI: 10.3390/children9111777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022]
Abstract
The implementation of early mobility programs for children with critical illnesses has been growing. Children with acute neurologic conditions that result in the requirement of an external ventricular drain (EVD) may be excluded from attaining the benefits of early mobility programs due to the fear of adverse events. The purpose of this study was to examine the implementation, safety, and outcomes of children with EVDs mobilized by physical therapists. A single-site retrospective cohort study of children with EVDs mobilized by physical therapy (PT) was conducted. Patients aged 3–21 years who were hospitalized from September 2016 to December 2020 were included in this study. Results: Out of a total of 192 electronic health records with EVDs, 168 patients (87.5%) participated in 1601 early mobilization encounters led by physical therapists. No adverse events occurred due to mobilization. Patients mobilized more frequently by PT had a higher level of activity at discharge (p = 0.014), a shorter length of stay (p = 0.001), and a more favorable discharge (p = 0.03). The early mobilization of children with EVDs can be implemented safely without adverse events. Patients mobilized with an EVD are more functional at discharge, spend fewer days in the hospital, and have a more favorable discharge compared to those who do not receive PT.
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Kamzan AD, Tsoi S, Arslanian T, Sim MS, Romero T, Newcomer CA. Admission Source Is Associated With the Risk of Rapid Response Team Activation in a Children's Hospital. Acad Pediatr 2022; 22:1477-1481. [PMID: 35858662 DOI: 10.1016/j.acap.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 06/16/2022] [Accepted: 06/19/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate source of admission to a children's hospital as a predictor of rapid response team (RRT) activation, both in the first 48 hours of admission and over the entire hospitalization. METHODS Retrospective cohort study of all patients admitted to the pediatric ward between March 1, 2013 and December 31, 2015. Source of admission was categorized as from the emergency department, transfer from another hospital facility, admission following a planned surgery, direct admission planned in advance, or unplanned direct admission. Information was collected including whether or not the patient had a RRT activation and survival to discharge. A Fisher's exact test was used to assess the association between source of admission and risk of rapid response. RESULTS Of 8083 admissions included in the study, 194 had at least one RRT event. The odds of having an RRT was significantly associated with source of admission (P < .001). Using admission from the emergency department as a reference group, planned elective admissions (odds ratio [OR] 0.27; P < .001) and admissions following planned surgery (OR 0.07; P < .001) were significantly associated with reduced odds of having at least one RRT activation during the admission. Planned elective admissions also demonstrated reduced odds of RRT in the first 48 hours of hospitalization (OR 0.14; P = .002). Source of admission was also associated with survival to discharge (P < .05). CONCLUSION Source of admission is associated with likelihood of RRT activation as well as with survival to discharge and should be considered by providers when assessing inpatient risk of decompensation.
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Affiliation(s)
- Audrey D Kamzan
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif.
| | - Stephanie Tsoi
- UCSF Department of Pediatrics (S Tsoi), San Francisco, Calif
| | - Talin Arslanian
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif
| | - Myung Shin Sim
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of General Internal Medicine and Health Services Research (MS Sim, T Romero), Los Angeles, Calif
| | - Tahmineh Romero
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of General Internal Medicine and Health Services Research (MS Sim, T Romero), Los Angeles, Calif
| | - Charles A Newcomer
- David Geffen School of Medicine (AD Kamzan, T Arslanian, MS Sim, T Romero, and CA Newcomer), Los Angeles, Calif; UCLA Department of Pediatrics (AD Kamzan, T Arslanian, and CA Newcomer), Los Angeles, Calif
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Chong SL, Goh MSL, Ong GYK, Acworth J, Sultana R, Yao SHW, Ng KC, Scholefield B, Aickin R, Maconochie I, Atkins D, Couto TB, Guerguerian AM, Kleinman M, Kloeck D, Nadkarni V, Nuthall G, Reis A, Rodriguez-Nunez A, Schexnayder S, Tijssen J, Van de Voorde P, Morley P. Do paediatric early warning systems reduce mortality and critical deterioration events among children? A systematic review and meta-analysis. Resusc Plus 2022; 11:100262. [PMID: 35801231 PMCID: PMC9253845 DOI: 10.1016/j.resplu.2022.100262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 11/17/2022] Open
Abstract
Aim We conducted a systematic review and meta-analysis to answer the question: Does the implementation of Paediatric Early Warning Systems (PEWS) in the hospital setting reduce mortality, cardiopulmonary arrests, unplanned codes and critical deterioration events among children, as compared to usual care without PEWS? Methods We conducted a comprehensive search using Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Web of Science. We included studies published between January 2006 and April 2022 on children <18 years old performed in inpatient units and emergency departments, and compared patient populations with PEWS to those without PEWS. We excluded studies without a comparator, case control studies, systematic reviews, and studies published in non-English languages. We employed a random effects meta-analysis and synthesised the risk and rate ratios from individual studies. We used the Scottish Intercollegiate Guidelines Network (SIGN) to appraise the risk of bias. Results Among 911 articles screened, 15 were included for descriptive analysis. Fourteen of the 15 studies were pre- versus post-implementation studies and one was a multi-centre cluster randomised controlled trial (RCT). Among 10 studies (580,604 hospital admissions) analysed for mortality, we found an increased risk (pooled RR 1.18, 95% CI 1.01–1.38, p = 0.036) in the group without PEWS compared to the group with PEWS. The sensitivity analysis performed without the RCT (436,065 hospital admissions) showed a non-significant relationship (pooled RR 1.17, 95% CI 0.98–1.40, p = 0.087). Among four studies (168,544 hospital admissions) analysed for unplanned code events, there was an increased risk in the group without PEWS (pooled RR 1.73, 95%CI 1.01–2.96, p = 0.046) There were no differences in the rate of cardiopulmonary arrests or critical deterioration events between groups. Our findings were limited by potential confounders and imprecision among included studies. Conclusions Healthcare systems that implemented PEWS were associated with reduced mortality and code rates. We recognise that these gains vary depending on resource availability and efferent response systems. PROSPERO registration: CRD42021269579.
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Rosman SL, Daneau Briscoe C, Rutare S, McCall N, Monuteaux MC, Unyuzumutima J, Uwamaliya A, Hitayezu J. The impact of pediatric early warning score and rapid response algorithm training and implementation on interprofessional collaboration in a resource-limited setting. PLoS One 2022; 17:e0270253. [PMID: 35731748 PMCID: PMC9216488 DOI: 10.1371/journal.pone.0270253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 06/07/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Improved teamwork and communication have been associated with improved quality of care. Early Warning Scores (EWS) and rapid response algorithms are a way of identifying deteriorating patients and providing a common framework for communication and response between physicians and nurses. The impact of EWS implementation on interprofessional collaboration (IPC) has been minimally studied, especially in resource-limited settings. Methods The study took place in the Pediatric Department of the main academic referral hospital in Rwanda between April 2019 and January 2020. Pediatric nurses and residents were trained on the use of the Pediatric Warning Score for Resource-Limited Settings (PEWS-RL) and a rapid response algorithm. Training included vital sign collection, PEWS-RL calculation, IPC and rapid response algorithm implementation. Prior to training, participants completed surveys on IPC with Likert scale responses (from “strongly disagree” to “strongly agree”). Follow-up surveys were then administered nine months later and also included an open-response question on the impact of the PEWS-RL implementation on IPC. Results Sixty-five (96%) nurses were trained and completed the pre-survey and thirty-seven (54%) of the trained nurses completed the post-survey. Twenty-two (59%) pediatric residents were trained in the workshop and completed the pre-survey and twenty-four physicians (4 pediatricians (40%) and 20 pediatric residents (53%)) completed the post-implementation survey. There was a statistically significant increase in the percent of nurses indicating strong agreement across all domains of communication and collaboration from the pre- to the post-survey. Although the percent of physicians indicating strong agreement increased in the post-survey for all items, only the “share information” item was statistically significant. Conclusion Training and implementation of a PEWS-RL and a rapid response algorithm at a tertiary hospital in Rwanda resulted in significant improvement of nurse and physician ratings of IPC nine months later.
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Affiliation(s)
- Samantha L. Rosman
- Division of Pediatric Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States of America
- * E-mail: (SLR); (CDB)
| | - Christine Daneau Briscoe
- Division of Hematology, Boston Children’s Hospital, Boston, MA, United States of America
- * E-mail: (SLR); (CDB)
| | - Samuel Rutare
- Department of Pediatrics, Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
| | - Natalie McCall
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, United States of America
| | - Michael C. Monuteaux
- Division of Pediatric Emergency Medicine, Boston Children’s Hospital, Boston, MA, United States of America
| | - Juliette Unyuzumutima
- Department of Pediatrics, Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
| | - Agnes Uwamaliya
- Department of Pediatrics, Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
| | - Janvier Hitayezu
- Department of Pediatrics, Centre Hospitalier Universitaire de Kigali (CHUK), Kigali, Rwanda
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Mehta SD, Muthu N, Yehya N, Galligan M, Porter E, McGowan N, Papili K, Favatella D, Liu H, Griffis H, Bonafide CP, Sutton RM. Leveraging EHR Data to Evaluate the Association of Late Recognition of Deterioration With Outcomes. Hosp Pediatr 2022; 12:447-460. [PMID: 35470399 DOI: 10.1542/hpeds.2021-006363] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Emergency transfers (ETs), deterioration events with late recognition requiring ICU interventions within 1 hour of transfer, are associated with adverse outcomes. We leveraged electronic health record (EHR) data to assess the association between ETs and outcomes. We also evaluated the association between intervention timing (urgency) and outcomes. METHODS We conducted a propensity-score-matched study of hospitalized children requiring ICU transfer between 2015 and 2019 at a single institution. The primary exposure was ET, automatically classified using Epic Clarity Data stored in our enterprise data warehouse endotracheal tube in lines/drains/airway flowsheet, vasopressor in medication administration record, and/or ≥60 ml/kg intravenous fluids in intake/output flowsheets recorded within 1 hour of transfer. Urgent intervention was defined as interventions within 12 hours of transfer. RESULTS Of 2037 index transfers, 129 (6.3%) met ET criteria. In the propensity-score-matched cohort (127 ET, 374 matched controls), ET was associated with higher in-hospital mortality (13% vs 6.1%; odds ratio, 2.47; 95% confidence interval [95% CI], 1.24-4.9, P = .01), longer ICU length of stay (subdistribution hazard ratio of ICU discharge 0.74; 95% CI, 0.61-0.91, P < .01), and longer posttransfer length of stay (SHR of hospital discharge 0.71; 95% CI, 0.56-0.90, P < .01). Increased intervention urgency was associated with increased mortality risk: 4.1% no intervention, 6.4% urgent intervention, and 10% emergent intervention. CONCLUSIONS An EHR measure of deterioration with late recognition is associated with increased mortality and length of stay. Mortality risk increased with intervention urgency. Leveraging EHR automation facilitates generalizability, multicenter collaboratives, and metric consistency.
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Affiliation(s)
- Sanjiv D Mehta
- aDepartments of Anesthesiology and Critical Care Medicine
| | | | - Nadir Yehya
- aDepartments of Anesthesiology and Critical Care Medicine
- dDepartment of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Ezra Porter
- eCenter for Healthcare Quality and Analytics
| | | | - Kelly Papili
- aDepartments of Anesthesiology and Critical Care Medicine
| | - Dana Favatella
- gCritical Care Center for Evidence and Outcomes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hongyan Liu
- hBiomedical and Health Informatics, Data Science and Biostatistics Unit
| | - Heather Griffis
- hBiomedical and Health Informatics, Data Science and Biostatistics Unit
| | | | - Robert M Sutton
- aDepartments of Anesthesiology and Critical Care Medicine
- dDepartment of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Feder J, Ramsay C, Tsampalieros A, Barrowman N, Richardson K, Rizakos S, Sweet J, McNally JD, Lobos AT. Relationship between Time of Day of Medical Emergency Team Activations and Outcomes of Hospitalized Pediatric Patients. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1744297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThis study was conducted to investigate whether outcomes of medical emergency team (MET) activations differ by time of day of in-hospitalized pediatric patients. This is a retrospective cohort study. Data were extracted from the charts of 846 patients (with one or more MET activations) over a 5-year period. It was conducted at Children's Hospital of Eastern Ontario, a tertiary pediatric hospital in Ottawa, Canada, affiliated with University of Ottawa. Patients included children <18 years, admitted to a pediatric ward, who experienced a MET activation between January 1, 2016 and December 31, 2020. We excluded patients reviewed by the MET during a routine follow-up, planned pediatric intensive care unit (PICU) admissions from the ward, and MET activation in out-patient settings, post-anesthesia care unit, and neonatal intensive care unit. There was no intervention. A total of 1,230 MET encounters were included as part of the final analysis. Daytime (08:00–15:59) MET activation was associated with increased PICU admission (25.3%, p = 0.04). There was some evidence of a higher proportion of critical deterioration events (CDEs) during daytime MET activation; however, this did not reach statistical significance (24%, p = 0.09). The highest MET dosage occurred during the evening hours, 16:00 to 23:59 (15/1,000 admissions), and it was lowest overnight, 00:00 to 07:59 (8.8/1,000 admissions, p < 0.001). This period of lowest MET dosage immediately preceded the highest likelihood of PICU admission (08:00, 37.5%) and CDE (09:00, 30.2%). Following the period of lowest MET activity overnight, MET activations during early daytime hours were associated with the highest likelihood of unplanned PICU admission and CDEs. This work identifies potential high-risk periods for undetected critical deterioration and targets for future quality improvement.
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Affiliation(s)
- Joshua Feder
- Department of Pediatrics, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Christa Ramsay
- Department of Respiratory Therapy, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Anne Tsampalieros
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Kara Richardson
- Department of Respiratory Therapy, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Sara Rizakos
- MD Candidate, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Julia Sweet
- MD Candidate, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - James Dayre McNally
- Department of Respiratory Therapy, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Division of Critical Care, Children's Hospital of Eastern Ontario, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Anna-Theresa Lobos
- Division of Critical Care, Children's Hospital of Eastern Ontario, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Lamsal R, Johnson JK, Mulla M, Marmet J, Somani A. Improving Communication by Standardizing Pediatric Rapid Response Team Documentation. J Healthc Qual 2022; 44:e1-e6. [PMID: 34772844 PMCID: PMC8716421 DOI: 10.1097/jhq.0000000000000334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Rapid response teams (RRTs) have been used by multiple hospital systems to enhance patient care and safety. However, processes to document rapid response events (RRE) are often varied among providers and teams, which can lead to suboptimal communication of recommendations to both the primary medical team and family. METHODS A preintervention chart review was conducted from January-March 2018 and revealed suboptimal baseline documentation following RREs. A literature review and survey of RRT team members led to the creation of a standardized document with an Epic SmartPhrase which included six key elements of RRE documentation: physical examination, intervention performed, response to intervention, plan of care, communication with care team, and communication with family. A postintervention chart review was completed from April-June 2019 to assess improvements in documentation with the use of this SmartPhrase. RESULTS There were 23 RRE activations in the postintervention period, of which 60.8% were due to respiratory distress. The documentation of the six key elements improved (p < .05) after SmartPhrase creation and serial educational interventions. CONCLUSIONS Standardized RRE documentation of six key elements significantly improved with the implementation of an Epic SmartPhrase. Improved quality of documentation enhances communication between team members and can contribute to safer patient care.
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Affiliation(s)
- Riwaaj Lamsal
- Department of Pediatrics, Division of Pediatric Critical Care, University of Minnesota, Minneapolis, USA
| | | | | | - Jordan Marmet
- Department of Pediatrics, Division of Hospital Medicine, University of Minnesota, Minneapolis, USA
| | - Arif Somani
- Department of Pediatrics, Division of Pediatric Critical Care, University of Minnesota, Minneapolis, USA
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21
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Sawicki JG, Tower D, Vukin E, Workman JK, Stoddard GJ, Burch M, Bracken DR, Hall B, Henricksen JW. Association Between Rapid Response Algorithms and Clinical Outcomes of Hospitalized Children. Hosp Pediatr 2021; 11:1385-1394. [PMID: 34849928 DOI: 10.1542/hpeds.2020-005603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To evaluate whether the implementation of clinical pathways, known as pediatric rapid response algorithms, within an existing rapid response system was associated with an improvement in clinical outcomes of hospitalized children. METHODS We retrospectively identified patients admitted to the PICU as unplanned transfers from the general medical and surgical floors at a single, freestanding children's hospital between July 1, 2017, and January 31, 2020. We examined the impact of the algorithms on the rate of critical deterioration events. We used multivariable Poisson regression and an interrupted time series analysis to measure 2 possible types of change: an immediate implementation effect and an outcome trajectory over time. RESULTS We identified 892 patients (median age: 4 [interquartile range: 1-12] years): 615 in the preimplementation group, and 277 in the postimplementation group. Algorithm implementation was not associated with an immediate change in the rate of critical deterioration events but was associated with a downward rate trajectory over time and a postimplementation trajectory that was significantly less than the preimplementation trajectory (trajectory difference of -0.28 events per 1000 non-ICU patient days per month; 95% confidence interval -0.40 to -0.16; P < .001). CONCLUSIONS Algorithm implementation was associated with a decrease in the rate of critical deterioration events. Because of the study's observational nature, this association may have been driven by unmeasured confounding factors and the chosen implementation point. Nevertheless, the results are a promising start for future research into how clinical pathways within a rapid response system can improve care of hospitalized patients.
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Affiliation(s)
| | | | | | - Jennifer K Workman
- Departments of Pediatrics
- Critical Care, Primary Children's Hospital, Salt Lake City, Utah
| | - Gregory J Stoddard
- Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Mary Burch
- Intermountain Healthcare, Salt Lake City, Utah
| | | | - Brooke Hall
- Intermountain Healthcare, Salt Lake City, Utah
| | - Jared W Henricksen
- Departments of Pediatrics
- Critical Care, Primary Children's Hospital, Salt Lake City, Utah
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22
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Slater A, Crosbie D, Essenstam D, Hoggard B, Holmes P, McEniery J, Thompson M. Decision-making for children requiring interhospital transport: assessment of a novel triage tool. Arch Dis Child 2021; 106:1184-1190. [PMID: 33931398 DOI: 10.1136/archdischild-2019-318634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/31/2021] [Accepted: 02/26/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The use of specialist retrieval teams to transport critically ill children is associated with reduced risk-adjusted mortality and morbidity; however, there is a paucity of data to guide decision-making related to retrieval team activation. We aimed to assess the accuracy of a novel triage tool designed to identify critically ill children at the time of referral for interhospital transport. DESIGN Prospective observational study. SETTING Regional paediatric retrieval and transport services. PATIENTS Data were collected for 1815 children referred consecutively for interhospital transport from 87 hospitals in Queensland and northern New South Wales. INTERVENTION Implementation of the Queensland Paediatric Transport Triage Tool. MAIN OUTCOME MEASURES Accuracy was assessed by calculating the sensitivity, specificity and negative predictive value for predicting transport by a retrieval team, or admission to intensive care following transport. RESULTS A total of 574 (32%) children were transported with a retrieval team. Prediction of retrieval (95% CIs): sensitivity 96.9% (95% CI 95.1% to 98.1%), specificity 91.4% (95% CI 89.7% to 92.9%), negative predictive value 98.4% (95% CI 97.5% to 99.1%). There were 412 (23%) children admitted to intensive care following transport. Prediction of intensive care admission: sensitivity 96.8% (95% CI 94.7% to 98.3%), specificity 81.2% (95% CI 79.0% to 83.2%), negative predictive value 98.9% (95% CI 98.1% to 99.4%). CONCLUSIONS The triage tool predicted the need for retrieval or intensive care admission with high sensitivity and specificity. The high negative predictive value indicates that, in our setting, children categorised as acutely ill rather than critically ill are generally suitable for interhospital transport without a retrieval team.
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Affiliation(s)
- Anthony Slater
- Children's Health Queensland Retrieval Service, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia .,School of Clinical Medicine, The University of Queensland, South Brisbane, Queensland, Australia
| | - Deanne Crosbie
- Telehealth Emergency Management Support Unit, Aeromedical Retrieval and Disaster Management Branch, Queensland Health, Kedron, Queensland, Australia
| | - Dionne Essenstam
- Children's Advice and Transport Coordination Hub, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Brett Hoggard
- Retrieval Service Queensland, Aeromedical Retrieval and Disaster Management Branch, Queensland Health, Kedron, Queensland, Australia
| | - Paul Holmes
- Children's Health Queensland Retrieval Service, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
| | - Julie McEniery
- Children's Health Queensland Retrieval Service, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia.,School of Clinical Medicine, The University of Queensland, South Brisbane, Queensland, Australia
| | - Michelle Thompson
- Children's Advice and Transport Coordination Hub, Children's Health Queensland Hospital and Health Service, South Brisbane, Queensland, Australia
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Abstract
INTRODUCTION The efficacy of a specialized pediatric cardiac rapid response team is unknown. We hypothesized that a specialized cardiac rapid response team would facilitate team-wide communication between the cardiac stepdown unit and cardiac intensive care unit (ICU) teams and improve patient care. MATERIALS AND METHODS A specialized pediatric cardiac rapid response team was implemented in June 2015. All pediatric cardiac rapid response team activations and outcomes from implementation through December 2018 were reviewed. Cardiac arrests and unplanned transfers to the cardiac ICU were indexed to 1000 patient-days to account for inpatient volume trends and evaluated over time. RESULTS There were 202 cardiac rapid response team activations in 108 unique patients during the study period. After implementation of the pediatric cardiac rapid response team, unplanned transfers from the cardiac stepdown unit to the cardiac ICU decreased from 16.8 to 7.1 transfers per 1000 patient days (p = 0.012). The stepdown unit cardiac arrest rate decreased from 1.2 to 0.0 arrests per 1000 patient-days (p = 0.015). There was one death on the cardiac stepdown unit in the 5 years since the implementation of the cardiac rapid response team, compared to four deaths in the previous 5 years. CONCLUSIONS A reduction in unplanned cardiac ICU transfers, cardiac arrests, and mortality on the cardiac stepdown unit has been observed since the implementation of a specialized pediatric cardiac rapid response team. A specialized cardiac rapid response team may improve communication and empower the interdisciplinary care team to escalate care for patients experiencing clinical decline.
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Jani P, Blood AD, Park YS, Xing K, Mitchell D. Simulation-Based Curricula for Enhanced Retention of Pediatric Resuscitation Skills: A Randomized Controlled Study. Pediatr Emerg Care 2021; 37:e645-e652. [PMID: 31305500 DOI: 10.1097/pec.0000000000001849] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Resuscitation skills decay as early as 4 months after course acquisition. Gaps in research remain regarding ideal educational modalities, timing, and frequency of curricula required to optimize skills retention. Our objective was to evaluate the impact on retention of resuscitation skills 8 months after the Pediatric Advanced Life Support (PALS) course when reinforced by an adjunct simulation-based curriculum 4 months after PALS certification. We hypothesized there would be improved retention in the intervention group. METHODS This is a partial, double-blind, randomized controlled study. First-year pediatric residents were randomized to an intervention or control group. The intervention group participated in a simulation-based curriculum grounded in principles of deliberate practice and debriefing. The control group received no intervention. T-tests were used to compare mean percent scores (M) from simulation-based assessments and multiple-choice tests immediately following the PALS course and after 8 months. RESULTS Intervention group (n = 12) had overall improved retention of resuscitation skills at 8 months when compared with the control group (n = 12) (mean, 0.57 ± 0.05 vs 0.52 ± 0.06; P = 0.037). No significant difference existed between individual skills stations. The intervention group had greater retention of cognitive knowledge (mean, 0.78 ± 0.09 vs 0.68 ± 0.14; P = 0.049). Residents performed 61% of assessment items correctly immediately following the PALS course. CONCLUSIONS Resuscitation skills acquisition from the PALS course and retention are suboptimal. These findings support the use of simulation-based curricula as course adjuncts to extend retention beyond 4 months.
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Affiliation(s)
| | | | - Yoon Soo Park
- Department of Medical Education, The University of Illinois at Chicago, Chicago, IL
| | - Kuan Xing
- Department of Medical Education, The University of Illinois at Chicago, Chicago, IL
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25
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Sosa T, Sitterding M, Dewan M, Coleman M, Seger B, Bedinghaus K, Hawkins D, Maddock B, Hausfeld J, Falcone R, Brady PW, Simmons J, White CM. Optimizing Situation Awareness to Reduce Emergency Transfers in Hospitalized Children. Pediatrics 2021; 148:peds.2020-034603. [PMID: 34599089 DOI: 10.1542/peds.2020-034603] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Interventions to improve care team situation awareness (SA) are associated with reduced rates of unrecognized clinical deterioration in hospitalized children. By addressing themes from recent safety events and emerging corruptors to SA in our system, we aimed to decrease emergency transfers (ETs) to the ICU by 50% over 10 months. METHODS An interdisciplinary team of physicians, nurses, respiratory therapists, and families convened to improve the original SA model for clinical deterioration and address communication inadequacies and evolving technology in our inpatient system. The key drivers included the establishment of a shared mental model, psychologically safe escalation, and efficient and effective SA tools. Novel interventions including the intentional inclusion of families and the interdisciplinary team in huddles, a mental model checklist, door signage, and an electronic health record SA navigator were evaluated via a time series analysis. Sequential inpatient-wide testing of the model allowed for iteration and consensus building across care teams and families. The primary outcome measure was ETs, defined as any ICU transfer in which the patient receives intubation, inotropes, or ≥3 fluid boluses within 1 hour. RESULTS The rate of ETs per 10 000 patient-days decreased from 1.34 to 0.41 during the study period. This coincided with special cause improvement in process measures, including risk recognition before medical response team activation and the use of tools to facilitate shared SA. CONCLUSIONS An innovative, proactive, and reliable process to predict, prevent, and respond to clinical deterioration was associated with a nearly 70% reduction in ETs.
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Affiliation(s)
| | | | - Maya Dewan
- Critical Care Medicine.,Biomedical Informatics.,Departments of Pediatrics
| | | | - Brandy Seger
- James M. Anderson Center for Health Systems Excellence
| | | | | | - Benjamin Maddock
- Pediatric Residency Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Richard Falcone
- Pediatric General and Thoracic Surgery.,Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Patrick W Brady
- Divisions of Hospital Medicine.,Departments of Pediatrics.,James M. Anderson Center for Health Systems Excellence
| | - Jeffrey Simmons
- Divisions of Hospital Medicine.,Departments of Pediatrics.,James M. Anderson Center for Health Systems Excellence
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26
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Gelbart B, Vidmar S, Stephens D, Cheng D, Thompson J, Segal A, Gadish T, Carlin J. Characteristics and outcomes of children receiving intensive care therapy within 12 hours following a medical emergency team event. CRIT CARE RESUSC 2021; 23:254-261. [PMID: 38046070 PMCID: PMC10692518 DOI: 10.51893/2021.3.oa2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: To describe characteristics and outcomes of children requiring intensive care therapy (ICT) within 12 hours following a medical emergency team (MET) event. Design: Retrospective cohort study. Setting: Quaternary paediatric hospital. Patients: Children experiencing a MET event. Measurements and main results: Between July 2017 and March 2019, 890 MET events occurred in 566 patients over 631 admissions. Admission to intensive care followed 183/890 (21%) MET events. 76/183 (42%) patients required ICT, defined as positive pressure ventilation or vasoactive support in intensive care, within 12 hours. Older children had a lower risk of requiring ICT than infants aged < 1 year (age 1-5 years [risk difference, -6.4%; 95% CI, -11% to -1.6%; P = 0.01] v age > 5 years [risk difference, -8.0%; 95% CI, -12% to -3.8%; P < 0.001]), while experiencing a critical event increased this risk (risk difference, 16%; 95% CI, 3.3-29%; P = 0.01). The duration of respiratory support and intensive care length of stay was approximately double in patients requiring ICT (ratio of geometric means, 2.0 [95% CI, 1.4-3.0] v 2.1 [95% CI, 1.5-2.8]; P < 0.001) and the intensive care mortality increased (risk difference, 9.6%; 95% CI, 2.4-17%; P = 0.01). Heart rate, oxygen saturation and respiratory rate were the most commonly measured vital signs in the 6 hours before the MET event. Conclusions: Approximately one-fifth of MET events resulted in intensive care admission and nearly half of these required ICT within 12 hours. This group had greater duration of respiratory support, intensive care and hospital length of stay, and higher mortality. Age < 1 year and a critical event increased the risk of ICT.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Suzanna Vidmar
- Clinical Epidemiology Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - David Stephens
- Decision Support Unit, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Daryl Cheng
- Department of Paediatrics, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Jenny Thompson
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ahuva Segal
- Royal Children's Hospital, Melbourne, VIC, Australia
| | - Tali Gadish
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - John Carlin
- Clinical Epidemiology Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
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van der Fluit KS, Boom MC, Brandão MB, Lopes GD, Barreto PG, Leite DCF, Gurgel RQ. How to implement a PEWS in a resource-limited setting: A quantitative analysis of the bedside-PEWS implementation in a hospital in northeast Brazil. Trop Med Int Health 2021; 26:1240-1247. [PMID: 34192384 PMCID: PMC8596539 DOI: 10.1111/tmi.13646] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Quantitative analysis of the implementation of the bedside paediatric early warning system (B-PEWS) in a resource-limited setting. The B-PEWS serves to pre-emptively identify hospitalised children who are at risk for cardiopulmonary arrest and subsequently to provide critical care in time. METHODS We performed a retrospective review through the medical data records of patients after discharge from the paediatric ward of a philanthropic hospital in Brazil. Nurses' performance using the system was measured with various parameters. RESULTS A total of 499 patients were included, and a total of 8024 scores were checked. During the 21-week research period, the implementation rate increased significantly from 66.5% (SD 26.0) in Period 1 to 93.1% (SD 16.6) in Period 2. The number of scores that resulted in a correct total score went from 7.5% in Period 1 to 32.2% in Period 2, p < 0.001. There was an improvement in the correct choice of age group between the two periods (from 32.2% to 53.4%). There was no difference in the mean admission time of patients in the two periods: in the first period 4.8 days (SD 2.9) and in the second period 4.8 days (SD 4.1). CONCLUSIONS It is possible to implement a PEWS in resource-limited settings while achieving high implementation rates. However, this is a time- and energy-consuming process. Having an active and involved team that is responsible for implementation is key for a successful implementation. Factors that likely hindered implementation were a large change in workflow for the nursing staff, non-native speakers as main investigators.
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Affiliation(s)
- Karin S van der Fluit
- Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Matthijs C Boom
- Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Marlon B Brandão
- Department of Pediatrics, Hospital e Maternidade Santa Isabel, Aracaju, Brazil.,Professional Graduate Program in Health Technological Management and Innovation, Federal University of Sergipe, Aracaju, Brazil
| | - Gabriel D Lopes
- Department of Pediatrics, Medicine Faculty, Tiradentes University, Aracaju, Brazil
| | - Paula G Barreto
- Department of Pediatrics, Medicine Faculty, Tiradentes University, Aracaju, Brazil
| | - Deborah C F Leite
- Department of Pediatrics, Medicine Faculty, Tiradentes University, Aracaju, Brazil
| | - Ricardo Q Gurgel
- Graduate Program in Health Sciences and Professional Graduate Program in Health Technological Management and Innovation, Federal University of Sergipe, Aracaju, Brazil
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Soeteman M, Kappen TH, van Engelen M, Kilsdonk E, Koomen E, Nieuwenhuis EES, Tissing WJE, Fiocco M, van den Heuvel-Eibrink M, Wösten-van Asperen RM. Identifying the critically ill paediatric oncology patient: a study protocol for a prospective observational cohort study for validation of a modified Bedside Paediatric Early Warning System score in hospitalised paediatric oncology patients. BMJ Open 2021; 11:e046360. [PMID: 34011596 PMCID: PMC8137214 DOI: 10.1136/bmjopen-2020-046360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Hospitalised paediatric oncology patients are at risk to develop acute complications. Early identification of clinical deterioration enabling adequate escalation of care remains challenging. Various Paediatric Early Warning Systems (PEWSs) have been evaluated, also in paediatric oncology patients but mostly in retrospective or case-control study designs. This study protocol encompasses the first prospective cohort with the aim of evaluating the predictive performance of a modified Bedside PEWS score for non-elective paediatric intensive care unit (PICU) admission or cardiopulmonary resuscitation in hospitalised paediatric oncology patients. METHODS AND ANALYSIS A prospective cohort study will be conducted at the 80-bed Dutch paediatric oncology hospital, where all national paediatric oncology care has been centralised, directly connected to a shared 22-bed PICU. All patients between 1 February 2019 and 1 February 2021 admitted to the inpatient nursing wards, aged 0-18 years, with an International Classification of Diseases for Oncology (ICD-O) diagnosis of paediatric malignancy will be eligible. A Cox proportional hazard regression model will be used to estimate the association between the modified Bedside PEWS and time to non-elective PICU transfer or cardiopulmonary arrest. Predictive performance (discrimination and calibration) will be assessed internally using resampling validation. To account for multiple occurrences of the event of interest within each patient, the unit of study is a single uninterrupted ward admission (a clinical episode). ETHICS AND DISSEMINATION The study protocol has been approved by the institutional ethical review board of our hospital (MEC protocol number 16-572/C). We adapted our enrolment procedure to General Data Protection Regulation compliance. Results will be disseminated at scientific conferences, regional educational sessions and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER Netherlands Trial Registry (NL8957).
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Affiliation(s)
- Marijn Soeteman
- Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
| | - Teus H Kappen
- Department of Department of Anaesthesia, Intensive Care and Emergency, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Ellen Kilsdonk
- Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
| | - Erik Koomen
- Department of Paediatric Intensive Care, University Medical Centre Utrecht/Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Edward E S Nieuwenhuis
- Department of Paediatrics, University Medical Centre Utrecht/Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Wim J E Tissing
- Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
- Department of Paediatric Oncology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Paediatric Oncology, Utrecht, The Netherlands
- Leiden University Mathematical Institute, Leiden, The Netherlands
| | | | - Roelie M Wösten-van Asperen
- Department of Paediatric Intensive Care, University Medical Centre Utrecht/Wilhelmina Children's Hospital, Utrecht, The Netherlands
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Study of the Relationship between ICU Patient Recovery and TCM Treatment in Acute Phase: A Retrospective Study Based on Python Data Mining Technology. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:5548157. [PMID: 33747101 PMCID: PMC7943298 DOI: 10.1155/2021/5548157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 11/17/2022]
Abstract
Background Data was mined with the help of an artificial intelligence system based on Python, data was collected, and a database was established using a Python crawler, and the relationship between the outcome of neurosurgery ICU patients and treatment using traditional Chinese medicine was ascertained through data management and statistical processing. Method The source data cases (n = 2237) were selected. By following the experimental design, data (n = 739) were obtained through artificial intelligence processing, including n = 480 in the group with traditional Chinese medicine treatment and n = 259 in the group without traditional Chinese medicine treatment. An evaluation was carried out using characteristics of patents' ICU stays and summated rating scales. Results There were statistical differences in 5 evaluation items (P < 0.05), and other comparison items also showed data with results favoring the outcomes in the intervention group using traditional Chinese medicine. Discussion. Traditional Chinese medicine as an alternative medical protocol effectively alleviates the stress and treatment fatigue brought about by modern medicine. Artificial intelligence data mining is a favorable medium to quantify this. Python will play a greater role in future clinical research because of its own characteristics.
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Morgan RW, Kirschen MP, Kilbaugh TJ, Sutton RM, Topjian AA. Pediatric In-Hospital Cardiac Arrest and Cardiopulmonary Resuscitation in the United States: A Review. JAMA Pediatr 2021; 175:293-302. [PMID: 33226408 PMCID: PMC8787313 DOI: 10.1001/jamapediatrics.2020.5039] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Pediatric in-hospital cardiac arrest (IHCA) occurs frequently and is associated with high morbidity and mortality. The objective of this narrative review is to summarize the current knowledge and recommendations regarding pediatric IHCA and cardiopulmonary resuscitation (CPR). OBSERVATIONS Each year, more than 15 000 children receive CPR for cardiac arrest during hospitalization in the United States. As many as 80% to 90% survive the event, but most patients do not survive to hospital discharge. Most IHCAs occur in intensive care units and other monitored settings and are associated with respiratory failure or shock. Bradycardia with poor perfusion is the initial rhythm in half of CPR events, and only about 10% of events have an initial shockable rhythm. Pre-cardiac arrest systems focus on identifying at-risk patients and ensuring that they are in monitored settings. Important components of CPR include high-quality chest compressions, timely defibrillation when indicated, appropriate ventilation and airway management, administration of epinephrine to increase coronary perfusion pressure, and treatment of the underlying cause of cardiac arrest. Extracorporeal CPR and measurement of physiological parameters are evolving areas in improving outcomes. Structured post-cardiac arrest care focused on targeted temperature management, optimization of hemodynamics, and careful intensive care unit management is associated with improved survival and neurological outcomes. CONCLUSIONS AND RELEVANCE Pediatric IHCA occurs frequently and has a high mortality rate. Early identification of risk, prevention, delivery of high-quality CPR, and post-cardiac arrest care can maximize the chances of achieving favorable outcomes. More research in this field is warranted.
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Affiliation(s)
- Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Matthew P. Kirschen
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Alexis A. Topjian
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Haga T, Kurosawa H, Maruyama J, Sakamoto K, Ikebe R, Tokuhira N, Takeuchi M. The prevalence and characteristics of rapid response systems in hospitals with pediatric intensive care units in Japan and barriers to their use. Int J Qual Health Care 2021; 32:325-331. [PMID: 32436575 DOI: 10.1093/intqhc/mzaa040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/23/2020] [Accepted: 03/31/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The use of pediatric rapid response systems (RRSs) to improve the safety of hospitalized children has spread in various western countries including the United States and the United Kingdom. We aimed to determine the prevalence and characteristics of pediatric RRSs and barriers to use in Japan, where epidemiological information is limited. DESIGN A cross-sectional online survey. SETTING All 34 hospitals in Japan with pediatric intensive care units (PICUs) in 2019. PARTICIPANTS One PICU physician per hospital responded to the questionnaire as a delegate. MAIN OUTCOME MEASURES Prevalence of pediatric RRSs in Japan and barriers to their use. RESULTS The survey response rate was 100%. Pediatric RRSs had been introduced in 14 (41.2%) institutions, and response teams comprised a median of 6 core members. Most response teams employed no full-time members and largely comprised members from multiple disciplines and departments who served in addition to their main duties. Of 20 institutions without pediatric RRSs, 11 (55%) hoped to introduce them, 14 (70%) had insufficient knowledge concerning them and 11 (55%) considered that their introduction might be difficult. The main barrier to adopting RRSs was a perceived personnel and/or funding shortage. There was no significant difference in hospital beds (mean, 472 vs. 524, P = 0.86) and PICU beds (mean, 10 vs. 8, P = 0.34) between institutions with/without pediatric RRSs. CONCLUSIONS Fewer than half of Japanese institutions with PICUs had pediatric RRSs. Operating methods for and obstructions to RRSs were diverse. Our findings may help to popularize pediatric RRSs.
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Affiliation(s)
- Taiki Haga
- Department of Pediatric Critical Care Medicine, Osaka City General Hospital, 2-13-22, Miyakojima-hondori, Miyakojima-ku, Osaka-City, Osaka, 534-0021, Japan
| | - Hiroshi Kurosawa
- Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, 1-6-7, Minatojimaminatomachi, Chuo-ku, Kobe-City, Hyogo, 650-0047, Japan
| | - Junji Maruyama
- Nursing Department, Intensive Care Center, Osaka City General Hospital, 2-13-22, Miyakojima-hondori, Miyakojima-ku, Osaka-City, Osaka, 534-0021, Japan
| | - Katsuko Sakamoto
- Nursing Department, Pediatric Intensive Care Unit, Hyogo Prefectural Kobe Children's Hospital, 1-6-7, Minatojimaminatomachi, Chuo-ku, Kobe-City, Hyogo, 650-0047, Japan
| | - Ryo Ikebe
- Nursing Department, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi-City, Osaka, 594-1101, Japan
| | - Natsuko Tokuhira
- Department of Anesthesiology, Japanese Red Cross Kyoto Daiichi Hospital, 15-749, Honmachi, Higashiyama-ku, Kyoto, 605-0981, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840, Murodo-cho, Izumi-City, Osaka, 594-1101, Japan
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Park SJ, Cho KJ, Kwon O, Park H, Lee Y, Shim WH, Park CR, Jhang WK. Development and validation of a deep-learning-based pediatric early warning system: A single-center study. Biomed J 2021; 45:155-168. [PMID: 35418352 PMCID: PMC9133255 DOI: 10.1016/j.bj.2021.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/23/2020] [Accepted: 01/11/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Seong Jong Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Kyung-Jae Cho
- VUNO, 6F-507 Gangnam-daero, Seocho-gu, Seoul, Republic of Korea
| | - Oyeon Kwon
- VUNO, 6F-507 Gangnam-daero, Seocho-gu, Seoul, Republic of Korea
| | - Hyunho Park
- VUNO, 6F-507 Gangnam-daero, Seocho-gu, Seoul, Republic of Korea
| | - Yeha Lee
- VUNO, 6F-507 Gangnam-daero, Seocho-gu, Seoul, Republic of Korea
| | - Woo Hyun Shim
- Department of Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chae Ri Park
- Department of Department of Medical Science, Asan Medical Institute of Convergence Science and Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Kyoung Jhang
- Department of Pediatrics, Asan Medical Center Children's Hospital, College of Medicine, University of Ulsan, Seoul, Republic of Korea.
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Shafi OM, Diego Rondon JD, Gulati G. Can the Pediatric Early Warning Score (PEWS) Predict Hospital Length of Stay? Cureus 2020; 12:e11339. [PMID: 33304675 PMCID: PMC7719480 DOI: 10.7759/cureus.11339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: Limited studies have evaluated the utility of scoring systems in the pediatric emergency department (PED) and no studies have evaluated their ability to predict hospital length of stay (LOS) and the usage of Observation units (OUs). Objective: To evaluate the utility of the Pediatric Early Warning Score (PEWS) in predicting LOS in pediatric patients and thus anticipate admission to an OU versus the pediatric ward. Methods: A retrospective study of pediatric inpatients (0 to 18 years) at an inner-city community hospital between January 2014 and December 2014. Patients with psychiatric illness, non-medical reasons for hospital stay, and those not discharged to ‘home’ were excluded. Demographic data, PEWS in the ED, and LOS for each patient were recorded and analyzed. Results: A total of 719 patients were analyzed. PEWS range was 0 to 8. The mean LOS was 56.8 hours for patients with PEWS 0-1 compared to 62.7 hours for patients with PEWS ≥2 (p=0.02). There was a significant difference in PEWS for LOS ≤24 and ≤36 hours in comparison to those with LOS >24 hours and >36 hours, respectively (p<0.001). Overall, the PEWS correlated with LOS (r=0.11, p=0.002). Age correlated inversely with LOS (r=-0.16, p<0.001), without correlation to PEWS (r=-0.002, p= 0.96). Conclusions: PEWS correlated weakly with LOS. A statistically significant lower PEWS was observed for patients who had short stays (both ≤24 and ≤36 hours) in comparison to those requiring longer inpatient care. Therefore, the PEWS is a useful tool to predict LOS and aid ED physicians to determine disposition, although further prospective studies in centers with OUs would better characterize its ability to suggest admission to an OU compared to the wards.
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Diurnal Variation in Medical Emergency Team Calls at a Tertiary Care Children's Hospital. Pediatr Qual Saf 2020; 5:e341. [PMID: 32984741 PMCID: PMC7480995 DOI: 10.1097/pq9.0000000000000341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 07/07/2020] [Indexed: 11/25/2022] Open
Abstract
Medical emergency teams (METs) bring critical care expertise to the bedsides of hospital ward patients who may be deteriorating. Diurnal variation in MET activation rates may identify inconsistencies in the detection of patients needing intervention. We aimed to determine whether such variation exists at our tertiary care children's hospital. Methods In this retrospective cohort study, we collected data including date and time of MET and disposition following MET for all inpatients at Cincinnati Children's Hospital Medical Center with a MET call between January 2008 and May 2014. The analysis compared the MET rate between days and nights, weekdays and weekends, and before and after nursing shift change. Results The number of METs per hour varied throughout the day. More METs were called during the day than at night (0.7 calls/shift ± 0.95 vs 0.6 ± 0.9, P < 0.001). There were also more METs per day on weekdays than weekends (1.4 ± 1 calls/d vs 1.2 ± 1, P < 0.001). Daytime METs were more likely to lead to transfer to the intensive care unit or operating room than those called at night (61.9% vs. 52.9%, P < 0.001). MET activation rates did not differ significantly in the 2 hours before nursing shift change compared to the 2 hours after. Conclusions At our large tertiary care children's hospital, there are both diurnal variations and variations across weekdays versus weekends in the MET activation rate. This difference may indicate variations in our ability to detect deteriorating patients on the wards and be further studied.
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Creamer KM, Ismail L, Smith K. Practice Makes Better: Making the Case for a Novel Hospitalist Resuscitation Curriculum. Hosp Pediatr 2020; 10:820-822. [PMID: 32801168 DOI: 10.1542/hpeds.2020-0147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Kevin M Creamer
- Children's National Hospital, Washington, District of Columbia
| | - Lana Ismail
- Children's National Hospital, Washington, District of Columbia
| | - Karen Smith
- Children's National Hospital, Washington, District of Columbia
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Acworth J, Dodson L, Acworth E, McEniery J. Changing patterns in paediatric medical emergency team (MET) activations over 20 years in a single specialist paediatric hospital. Resusc Plus 2020; 3:100025. [PMID: 34223308 PMCID: PMC8244408 DOI: 10.1016/j.resplu.2020.100025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/10/2020] [Accepted: 08/11/2020] [Indexed: 12/01/2022] Open
Abstract
Background The Medical Emergency Team (MET) model was first introduced in the early 1990s and aimed to intervene at an earlier stage of patient clinical deterioration. This study aimed to describe the changes in patient demographics, patterns of activation and clinical outcomes of MET activations at our specialist paediatric hospital across a 20-year period providing the longest duration Medical Emergency Team data set published to date. Methods This single-centre observational study prospectively collected data about MET events at a single specialist paediatric hospital in Australia from 1995 to 2014. Patient demographics, activation patterns and clinical outcomes from MET activations were analysed for the 20-year period. Results 771 MET events were included in analysis. Most MET events involved children aged <5 years (median age 36 months) with decreased incidence on weekends and night shift. The most frequent reasons stated for MET activation were seizure and respiratory compromise and the most commonly recorded MET interventions were bag-valve-mask ventilation and intravascular access. There was an increase in MET event frequency (MET events per 1000 hospital separations) in the second decade of the service compared to the first (3.25 vs 1.42, p < 0.001) with fewer events for cardiopulmonary arrest but more for respiratory, cardiovascular or neurological compromise. Conclusions This study describes the longest duration MET data set published to date. The 20-year span of data demonstrates increased utilisation of the MET system and activation for patients earlier in their deterioration. The data should inform both health service planning and educational requirements for MET providers.
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Affiliation(s)
- Jason Acworth
- Queensland Children's Hospital, 501 Stanley St, South Brisbane, Queensland, 4101, Australia.,Faculty of Medicine, University of Queensland, Herston Rd, Herston, Queensland, 4006, Australia
| | - Louise Dodson
- Queensland Children's Hospital, 501 Stanley St, South Brisbane, Queensland, 4101, Australia
| | - Elliott Acworth
- Faculty of Medicine, University of Queensland, Herston Rd, Herston, Queensland, 4006, Australia
| | - Julie McEniery
- Queensland Children's Hospital, 501 Stanley St, South Brisbane, Queensland, 4101, Australia
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The Vitals Risk Index-Retrospective Performance Analysis of an Automated and Objective Pediatric Early Warning System. Pediatr Qual Saf 2020; 5:e271. [PMID: 32426637 PMCID: PMC7190256 DOI: 10.1097/pq9.0000000000000271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 02/17/2020] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Pediatric in-hospital cardiac arrests and emergent transfers to the pediatric intensive care unit (ICU) represent a serious patient safety concern with associated increased morbidity and mortality. Some institutions have turned to the electronic health record and predictive analytics in search of earlier and more accurate detection of patients at risk for decompensation. Methods: Objective electronic health record data from 2011 to 2017 was utilized to develop an automated early warning system score aimed at identifying hospitalized children at risk of clinical deterioration. Five vital sign measurements and supplemental oxygen requirement data were used to build the Vitals Risk Index (VRI) model, using multivariate logistic regression. We compared the VRI to the hospital’s existing early warning system, an adaptation of Monaghan’s Pediatric Early Warning Score system (PEWS). The patient population included hospitalized children 18 years of age and younger while being cared for outside of the ICU. This dataset included 158 case hospitalizations (102 emergent transfers to the ICU and 56 “code blue” events) and 135,597 control hospitalizations. Results: When identifying deteriorating patients 2 hours before an event, there was no significant difference between Pediatric Early Warning Score and VRI’s areas under the receiver operating characteristic curve at false-positive rates ≤ 10% (pAUC10 of 0.065 and 0.064, respectively; P = 0.74), a threshold chosen to compare the 2 approaches under clinically tolerable false-positive rates. Conclusions: The VRI represents an objective, simple, and automated predictive analytics tool for identifying hospitalized pediatric patients at risk of deteriorating outside of the ICU setting.
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Molyneux EM. Cardiopulmonary resuscitation in poorly resourced settings: better to pre-empt than to wait until it is too late. Paediatr Int Child Health 2020; 40:1-6. [PMID: 31116094 DOI: 10.1080/20469047.2019.1616150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- E M Molyneux
- College of Medicine, University of Malawi, Blantyre, Malawi,
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Al-Omari A, Al Mutair A, Aljamaan F. Outcomes of rapid response team implementation in tertiary private hospitals: a prospective cohort study. Int J Emerg Med 2019; 12:31. [PMID: 31666005 PMCID: PMC6822364 DOI: 10.1186/s12245-019-0248-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiopulmonary arrest may result in high mortality rate in hospitals where the rapid response team is not implemented. A rapid response system can recognize patients at high risk of cardiopulmonary arrest and provide the needed medical management to prevent further deterioration. The rapid response system has shown a dramatic reduction in mortality rate and cardiopulmonary arrest. OBJECTIVE To evaluate the effectiveness of the rapid response team (RRT) implementation in reducing the mortality rate, number of cardiopulmonary arrests, and number of ICU admission. DESIGN A pre- and post-rapid response team system implementation. SETTING Four tertiary private hospitals in Saudi Arabia. PATIENTS A total of 154,869 patients in the 3-year before rapid response system period (January 2010 to December 2012) and a total of 466,161 during the 2.5-year post-RRT implementation period (January 2014 to June 2016). RESULTS Results indicated that ward nurses activated RRT more often than physicians (1104 activations [69%] vs. 499 activations [31%]), with cardiovascular and respiratory abnormalities being the most common triggers. Serious concern about the patient condition by the ward staff was the trigger for 181 (11.29%) activations. The RRT provided a variety of diagnostic and therapeutic interventions. Most patients cared for by RRT were admitted to ICU 1103 (68.81%), and the rest 500 (31.19%) were managed in the ward. After the implementation of the RRT project, the hospital mortality rate dropped from 7.8 to 2.8 per 1000 hospital admission. Hospital cardiopulmonary arrest rate has dropped from 10.53 per 1000 hospital admissions to 2.58. Rapid response team implementation also facilitated end-of-life care discussions. CONCLUSION Implementation of the RRT project has shown a dramatic reduction in the total ICU admissions, average ICU occupancy rate, total hospital mortality, and total ICU mortality. These findings reinforce the evidence that RRT implementation is effective in reducing hospital mortality and cardiopulmonary arrest rates in addition to other outcomes related to healthcare quality.
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Affiliation(s)
- Awad Al-Omari
- Research Center, Dr. Sulaiman Al Habib Medical Group, King Fahad Road - Olaya, P. O. Box 301578, Riyadh, 11643, Kingdom of Saudi Arabia.,Alfaisal University, King Fahad Road - Olaya, P. O. Box 301578, Riyadh, 11643, Kingdom of Saudi Arabia
| | - Abbas Al Mutair
- Research Center, Dr. Sulaiman Al Habib Medical Group, King Fahad Road - Olaya, P. O. Box 301578, Riyadh, 11643, Kingdom of Saudi Arabia. .,Alfaisal University, King Fahad Road - Olaya, P. O. Box 301578, Riyadh, 11643, Kingdom of Saudi Arabia. .,School of Nursing, Wollongong University, Wollongong, Australia. .,Health Sciences College, University of Sharjah, Sharjah, United Arab Emirates.
| | - Fadi Aljamaan
- King Saud University, P. O. Box 301578, 11643, King Fahad Road - Olaya, Riyadh, Kingdom of Saudi Arabia
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Healthcare Provider Perceptions of Cardiopulmonary Resuscitation Quality During Simulation Training. Pediatr Crit Care Med 2019; 20:e473-e479. [PMID: 31232856 DOI: 10.1097/pcc.0000000000002058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To assess the relationship between quantitative and perceived cardiopulmonary resuscitation performance when healthcare providers have access to and familiarity with audiovisual feedback devices. DESIGN Prospective observational study. SETTING In situ simulation events throughout a pediatric quaternary care center where the use of continuous audiovisual feedback devices during cardiopulmonary resuscitation is standard. SUBJECTS Healthcare providers who serve as first responders to in-hospital cardiopulmonary arrest. INTERVENTIONS High-fidelity simulation of resuscitation with continuous audiovisual feedback. MEASUREMENTS AND MAIN RESULTS Objective data was collected using accelerometer-based measurements from a cardiopulmonary resuscitation defibrillator/monitor. After the simulation event but before any debriefing, participants completed self-evaluation forms to assess whether they believed the cardiopulmonary resuscitation performed met the American Heart Association guidelines for chest compression rate, chest compression depth, chest compression fraction, chest compression in target, and duration of preshock pause and postshock pause. An association coefficient (kappa) was calculated to determine degree of agreement between perceived performance and the quantitative performance data that was collected from the CPR defibrillator/monitor. Data from 27 mock codes and 236 participants was analyzed. Average cardiopulmonary resuscitation performance was chest compression rate 106 ± 10 compressions per minute; chest compression depth 2.05 ± 0.6 in; chest compression fraction 74% ± 10%; chest compression in target 22% ± 21%; preshock pause 8.6 ± 7.2 seconds; and postshock pause 6.4 ± 8.9 seconds. When all healthcare providers were analyzed, the association coefficient (κ) for chest compression rate (κ = 0.078), chest compression depth (κ = 0.092), chest compression fraction (κ = 0.004), preshock pause (κ = 0.321), and postshock pause (κ = 0.40) was low, with no variable achieving moderate agreement (κ > 0.4). CONCLUSIONS Cardiopulmonary resuscitation performance during mock codes does not meet the American Heart Association's quality recommendations. Healthcare providers have poor insight into the quality of cardiopulmonary resuscitation during mock codes despite access to and familiarity with continuous audiovisual feedback.
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Zurca AD, Olsen N, Lucas R. Development and Validation of the Pediatric Resuscitation and Escalation of Care Self-Efficacy Scale. Hosp Pediatr 2019; 9:801-807. [PMID: 31554648 DOI: 10.1542/hpeds.2019-0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To validate a scale to assess pediatric providers' resuscitation and escalation of care self-efficacy and assess which provider characteristics and experiences may contribute to self-efficacy. METHODS Cross-sectional cohort study performed at an academic children's hospital. Pediatric nurses, respiratory therapists, and residents completed the Generalized Self-Efficacy Scale (GSES) and Pediatric Resuscitation Self-Efficacy Scale (PRSES) as well as a survey assessing their experiences with pediatric escalation of care. RESULTS Four hundred participants completed the GSES and PRSES. A total of 338 completed the survey, including 262 nurses, 51 respiratory therapists, and 25 residents. Cronbach α for the PRSES was 0.905. A factor analysis revealed 2 factors within the scale, with items grouped on the basis of expertise required. Multiple logistic regression analyses controlling for GSES score, number of code blue events participated, number of code blue events activated, number of rapid response team events participated, number of rapid response team response events called, performance on a knowledge assessment of appropriate escalation of care, and years of experience demonstrated that PRSES performance was significantly associated with GSES scores and number of escalation of care events (code blue and rapid response) previously participated in (R 2 = 0.29, P < .001). CONCLUSIONS The PRSES can be used to assess pediatric providers' pediatric resuscitation self-efficacy and could be used to evaluate pediatric escalation of care interventions. Pediatric resuscitation self-efficacy is significantly associated with number of previous escalation of care experiences. In future studies, researchers should focus on assessing the impact of increased exposures to escalation of care, potentially via mock codes, to accelerate the acquisition of resuscitation self-efficacy.
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Affiliation(s)
- Adrian D Zurca
- Department of Pediatrics, Penn State Hershey Children's Hospital, Hershey, Pennsylvania;
| | - Nils Olsen
- Department of Organizational Sciences and Communication, Columbian College of Arts and Sciences and
| | - Raymond Lucas
- Department of Emergency Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC
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Cheng A, Nadkarni VM, Mancini MB, Hunt EA, Sinz EH, Merchant RM, Donoghue A, Duff JP, Eppich W, Auerbach M, Bigham BL, Blewer AL, Chan PS, Bhanji F. Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2019; 138:e82-e122. [PMID: 29930020 DOI: 10.1161/cir.0000000000000583] [Citation(s) in RCA: 176] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.
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Ho AMH, Phelan R, Mizubuti GB, Murdoch JAC, Wickett S, Ho AK, Shyam V, Gilron I. Bias in Before-After Studies: Narrative Overview for Anesthesiologists. Anesth Analg 2019; 126:1755-1762. [PMID: 29239959 DOI: 10.1213/ane.0000000000002705] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Before-after study designs are effective research tools and in some cases, have changed practice. These designs, however, are inherently susceptible to bias (ie, systematic errors) that are sometimes subtle but can invalidate their conclusions. This overview provides examples of before-after studies relevant to anesthesiologists to illustrate potential sources of bias, including selection/assignment, history, regression to the mean, test-retest, maturation, observer, retrospective, Hawthorne, instrumentation, attrition, and reporting/publication bias. Mitigating strategies include using a control group, blinding, matching before and after cohorts, minimizing the time lag between cohorts, using prospective data collection with consistent measuring/reporting criteria, time series data collection, and/or alternative study designs, when possible. Improved reporting with enforcement of the Enhancing Quality and Transparency of Health Research (EQUATOR) checklists will serve to increase transparency and aid in interpretation. By highlighting the potential types of bias and strategies to improve transparency and mitigate flaws, this overview aims to better equip anesthesiologists in designing and/or critically appraising before-after studies.
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Affiliation(s)
- Anthony M H Ho
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rachel Phelan
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Glenio B Mizubuti
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - John A C Murdoch
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sarah Wickett
- Bracken Health Sciences Library, Queen's University, Kingston, Ontario, Canada
| | - Adrienne K Ho
- City Hospital and Queen's Medical Center, Nottingham, United Kingdom
| | - Vidur Shyam
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ian Gilron
- From the Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
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A Retrospective Case-Control Study to Identify Predictors of Unplanned Admission to Pediatric Intensive Care Within 24 Hours of Hospitalization. Pediatr Crit Care Med 2019; 20:e293-e300. [PMID: 31149966 DOI: 10.1097/pcc.0000000000001977] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To identify the clinical findings available at the time of hospitalization from the emergency department that are associated with deterioration within 24 hours. DESIGN A retrospective case-control study. SETTING A pediatric hospital in Ottawa, ON, Canada. PATIENTS Children less than 18 years old who were hospitalized via the emergency department between January 1, 2008, and December 31, 2012. Cases (n = 98) had an unplanned admission to the PICU or unexpected death on the hospital ward within 24 hours of hospitalization and controls (n = 196) did not. INTERVENTIONS None. MAIN RESULTS Ninety-eight children (53% boys; mean age 63.2 mo) required early unplanned admission to the PICU. Multivariable conditional logistic regression resulted in a model with five predictors reaching statistical significance: higher triage acuity score (odds ratio, 4.1; 95% CI, 1.7-10.2), tachypnea in the emergency department (odds ratio, 4.6; 95% CI, 1.8-11.8), tachycardia in the emergency department (odds ratio, 2.6; 95% CI, 1.1-6.5), PICU consultation in the emergency department (odds ratio, 8.0; 95% CI, 1.1-57.7), and admission to a ward not typical for age and/or diagnosis (odds ratio, 4.5; 95% CI, 1.7-11.6). CONCLUSIONS We have identified risk factors that should be included as potential predictor variables in future large, prospective studies to derive and validate a weighted scoring system to identify hospitalized children at high risk of early clinical deterioration.
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Trubey R, Huang C, Lugg-Widger FV, Hood K, Allen D, Edwards D, Lacy D, Lloyd A, Mann M, Mason B, Oliver A, Roland D, Sefton G, Skone R, Thomas-Jones E, Tume LN, Powell C. Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review. BMJ Open 2019; 9:e022105. [PMID: 31061010 PMCID: PMC6502038 DOI: 10.1136/bmjopen-2018-022105] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess (1) how well validated existing paediatric track and trigger tools (PTTT) are for predicting adverse outcomes in hospitalised children, and (2) how effective broader paediatric early warning systems are at reducing adverse outcomes in hospitalised children. DESIGN Systematic review. DATA SOURCES British Nursing Index, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effectiveness, EMBASE, Health Management Information Centre, Medline, Medline in Process, Scopus and Web of Knowledge searched through May 2018. ELIGIBILITY CRITERIA We included (1) papers reporting on the development or validation of a PTTT or (2) the implementation of a broader early warning system in paediatric units (age 0-18 years), where adverse outcome metrics were reported. Several study designs were considered. DATA EXTRACTION AND SYNTHESIS Data extraction was conducted by two independent reviewers using template forms. Studies were quality assessed using a modified Downs and Black rating scale. RESULTS 36 validation studies and 30 effectiveness studies were included, with 27 unique PTTT identified. Validation studies were largely retrospective case-control studies or chart reviews, while effectiveness studies were predominantly uncontrolled before-after studies. Metrics of adverse outcomes varied considerably. Some PTTT demonstrated good diagnostic accuracy in retrospective case-control studies (primarily for predicting paediatric intensive care unit transfers), but positive predictive value was consistently low, suggesting potential for alarm fatigue. A small number of effectiveness studies reported significant decreases in mortality, arrests or code calls, but were limited by methodological concerns. Overall, there was limited evidence of paediatric early warning system interventions leading to reductions in deterioration. CONCLUSION There are several fundamental methodological limitations in the PTTT literature, and the predominance of single-site studies carried out in specialist centres greatly limits generalisability. With limited evidence of effectiveness, calls to make PTTT mandatory across all paediatric units are not supported by the evidence base. PROSPERO REGISTRATION NUMBER CRD42015015326.
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Affiliation(s)
- Rob Trubey
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Chao Huang
- Hull York Medical School, University of Hull, Hull, UK
| | | | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Davina Allen
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Dawn Edwards
- Department of Paediatrics, Morriston Hospital, Swansea, UK
| | - David Lacy
- Wirral University Teaching Hospital, Wirral, UK
| | - Amy Lloyd
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mala Mann
- University Library Services, Cardiff University, Cardiff, UK
| | | | - Alison Oliver
- Department of Paediatric Intensive Care, Noah’s Ark Children’s Hospital for Wales, Cardiff, UK
| | - Damian Roland
- SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children’s Emergency Department, Leicester Royal Infirmary, Leicester, UK
| | - Gerri Sefton
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Richard Skone
- Department of Paediatric Intensive Care, Noah’s Ark Children’s Hospital for Wales, Cardiff, UK
| | | | - Lyvonne N Tume
- Faculty of Health and Applied Sciences (HAS), University of the West of England Bristol, Bristol, UK
| | - Colin Powell
- Department of Pediatric Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Molyneux E. Forewarned Is Forearmed. Pediatrics 2019; 143:peds.2018-4058. [PMID: 30992307 DOI: 10.1542/peds.2018-4058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Elizabeth Molyneux
- Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
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Rosman SL, Karangwa V, Law M, Monuteaux MC, Briscoe CD, McCall N. Provisional Validation of a Pediatric Early Warning Score for Resource-Limited Settings. Pediatrics 2019; 143:peds.2018-3657. [PMID: 30992308 DOI: 10.1542/peds.2018-3657] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The use of Pediatric Early Warning Scores is becoming widespread to identify and rapidly respond to patients with deteriorating conditions. The ability of Pediatric Early Warning Scores to identify children at high risk of deterioration or death has not, however, been established in resource-limited settings. METHODS We developed the Pediatric Early Warning Score for Resource-Limited Settings (PEWS-RL) on the basis of expert opinion and existing scores. The PEWS-RL was derived from 6 equally weighted variables, producing a cumulative score of 0 to 6. We then conducted a case-control study of admissions to the pediatrics department of the main public referral hospital in Kigali, Rwanda between November 2016 and March 2017. We defined case patients as children fulfilling the criteria for clinical deterioration, who were then matched with controls of the same age and hospital ward. RESULTS During the study period, 627 children were admitted, from whom we selected 79 case patients and 79 controls. For a PEWS-RL of ≥3, sensitivity was 96.2%, and specificity was 87.3% for identifying patients at risk for clinical deterioration. A total PEWS-RL of ≥3 was associated with a substantially increased risk of clinical deterioration (odds ratio 129.3; 95% confidence interval 38.8-431.6; P <.005). CONCLUSIONS This study reveals that the PEWS-RL, a simple score based on vital signs, mental status, and presence of respiratory distress, was feasible to implement in a resource-limited setting and was able to identify children at risk for clinical deterioration.
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Affiliation(s)
| | - Valens Karangwa
- Department of Pediatrics, University of Rwanda, Kigali, Rwanda
| | - Michael Law
- Center for Health Services and Policy Research, The University of British Columbia, Vancouver, Canada.,Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | | | | | - Natalie McCall
- Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut
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Lockwood J, Reese J, Wathen B, Thomas J, Brittan M, Iwanowski M, McLeod L. The Association Between Fever and Subsequent Deterioration Among Hospitalized Children With Elevated PEWS. Hosp Pediatr 2019; 9:170-178. [PMID: 30760491 PMCID: PMC6391037 DOI: 10.1542/hpeds.2018-0187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To evaluate the association between fever and subsequent deterioration among patients with Pediatric Early Warning Score (PEWS) elevations to ≥4 to inform improvements to care escalation processes at our institution. METHODS We performed a cohort study of hospitalized children at a single quaternary children's hospital with PEWS elevations to ≥4 between January 1, 2014 and March 31, 2014. Bivariable analysis was used to compare characteristics between patients with and without unplanned ICU transfers and critical deterioration events (CDEs) (ie, unplanned ICU transfers with life-sustaining interventions initiated in the first 12 ICU hours). A multivariable Poisson regression was used to assess the relative risk of unplanned ICU transfers and CDEs. RESULTS The study population included 220 PEWS elevations from 176 unique patients. Of those, 33% had fever (n = 73), 40% experienced an unplanned ICU transfer (n = 88), and 19% experienced CDEs (n = 42). Bivariable analysis revealed that febrile patients were less likely to experience an unplanned ICU transfer than those without fever. The same association was found in multivariable analysis with only marginal significance (adjusted relative risk 0.68; 95% confidence interval 0.45-1.01; P = .058). There was no difference in the CDE risk for febrile versus afebrile patients (adjusted relative risk 0.79; 95% confidence interval 0.43-1.44; P = .44). CONCLUSIONS At our institution, patients with an elevated PEWS appeared less likely to experience an unplanned ICU transfer if they were febrile. We were underpowered to evaluate the effect on CDEs. These findings contributed to our recognition that (1) PEWS may not include all relevant clinical factors used for clinical decision-making regarding care escalation and (2) further study is needed in this area.
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Affiliation(s)
- Justin Lockwood
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, and
- Children's Hospital Colorado, Aurora, Colorado
| | - Jennifer Reese
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, and
- Children's Hospital Colorado, Aurora, Colorado
| | - Beth Wathen
- PICU and
- Children's Hospital Colorado, Aurora, Colorado
| | - Jacob Thomas
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado; and
- Children's Hospital Colorado, Aurora, Colorado
| | - Mark Brittan
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, and
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado; and
- Children's Hospital Colorado, Aurora, Colorado
| | - Melissa Iwanowski
- Children's Hospital Colorado, Aurora, Colorado
- Quality and Patient Safety
| | - Lisa McLeod
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, and
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, Colorado; and
- Children's Hospital Colorado, Aurora, Colorado
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Efficacy and Safety of Pediatric Critical Care Physician Telemedicine Involvement in Rapid Response Team and Code Response in a Satellite Facility. Pediatr Crit Care Med 2019; 20:172-177. [PMID: 30395026 PMCID: PMC6363847 DOI: 10.1097/pcc.0000000000001796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Satellite inpatient facilities of larger children's hospitals often do not have on-site intensivist support. In-house rapid response teams and code teams may be difficult to operationalize in such facilities. We developed a system using telemedicine to provide pediatric intensivist involvement in rapid response team and code teams at the satellite facility of our children's hospital. Herein, we compare this model with our in-person model at our main campus. DESIGN Cross-sectional. SETTING A tertiary pediatric center and its satellite facility. PATIENTS Patients admitted to the satellite facility. INTERVENTIONS Implementation of a rapid response team and code team model at a satellite facility using telemedicine to provide intensivist support. MEASUREMENTS AND MAIN RESULTS We evaluated the success of the telemedicine model through three a priori outcomes: 1) reliability: involvement of intensivist on telemedicine rapid response teams and codes, 2) efficiency: time from rapid response team and code call until intensivist response, and 3) outcomes: disposition of telemedicine rapid response team or code calls. We compared each metric from our telemedicine model with our established main campus model. MAIN RESULTS Critical care was involved in satellite campus rapid response team activations reliably (94.6% of the time). The process was efficient (median response time 7 min; mean 8.44 min) and effective (54.5 % patients transferred to PICU, similar to the 45-55% monthly rate at main campus). For code activations, the critical care telemedicine response rate was 100% (6/6), with a fast response time (median 1.5 min). We found no additional risk to patients, with no patients transferred from the satellite campus requiring a rapid escalation of care defined as initiation of vasoactive support, greater than 60 mL/kg in fluid resuscitation, or endotracheal intubation. CONCLUSIONS Telemedicine can provide reliable, timely, and effective critical care involvement in rapid response team and Code Teams at satellite facilities.
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Abstract
BACKGROUND This 3-year study measured the satisfaction of staff nurses with medical emergency team (MET) nurse services at a 573-bed hospital in the south from 2015 through 2017. Nurse satisfaction is a key management issue. Barriers to effective MET use can negatively impact patient outcomes, staffing, and nurse turnover. OBJECTIVES The purpose of this study was to assess nurse satisfaction with MET nurses at a large county hospital in the south over a 3-year period. METHODS Satisfaction was analyzed by shift, nurse role, the number of times the nurse contacted the MET nurse, and the way in which contact was initiated (MET nurse initiated vs nurse initiated). In addition, nurses responded to open-ended questions. RESULTS Nurse satisfaction with MET nurse services was improved with both education and communication over time and stabilized over the 3-year period. More than 95% of nurses were satisfied or very satisfied overall with MET nurse services. There were statistically significant differences in satisfaction by shift worked, nurse role, and method of activation. There were no statistically significant differences by nursing floor. DISCUSSION Nurse leaders can consider this MET nurse service as a potential model to help with increasing staff satisfaction, staff engagement, and, potentially, staff retention. More than 95% of nurses were satisfied or very satisfied overall with MET nurse services.
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