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Piazza AJ, Brozanski B, Grover T, Chuo J, Mingrone T, Rao R, Smith J, Soliman D, Rintoul N, Bellflower B, Richardson T, Holston M, McClead R, Guidash J, Pallotto EK. STEPP IN: A Multicenter Quality Improvement Collaborative Standardizing Postoperative Handoffs. Pediatrics 2021; 148:183430. [PMID: 34851419 DOI: 10.1542/peds.2020-016402] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To reduce care failures by 30% through implementation of standardized communication processes for postoperative handoff in NICU patients undergoing surgery over 12 months and sustained over 6 months. METHODS Nineteen Children's Hospitals Neonatal Consortium centers collaborated in a quality improvement initiative to reduce postoperative care failures in a surgical neonatal setting by decreasing respiratory care failures and all other communication failures. Evidence-based clinical practice recommendations and a collaborative framework supported local teams' implementation of standardized postoperative handoff communication. Process measures included compliance with center-defined handoff staff presence, use of center-defined handoff tool, and the proportion of handoffs with interruptions. Participant handoff satisfaction was the balancing measure. Baseline data were collected for 8 months, followed by a 12-month action phase and 7-month sustain phase. RESULTS On average, 181 postoperative handoffs per month were monitored across sites, and 320 respondents per month assessed the handoff process. Communication failures specific to respiratory care decreased by 73.2% (8.2% to 4.6% and with a second special cause signal to 2.2%). All other communication care failures decreased by 49.4% (17% to 8.6%). Eighty-four percent of participants reported high satisfaction. Compliance with use of the handoff tool and required staff attendance increased whereas interruptions decreased over the project time line. CONCLUSIONS Team engagement within a quality improvement framework had a positive impact on the perioperative handoff process for high-risk surgical neonates. We improved care as demonstrated by a decrease in postoperative care failures while maintaining high provider satisfaction.
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Affiliation(s)
- Anthony J Piazza
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
| | - Beverly Brozanski
- School of Medicine, Washington University and St Louis Children's Hospital, St Louis, Missouri
| | - Theresa Grover
- Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado
| | - John Chuo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Rakesh Rao
- Department of Pediatrics, St Louis Children's Hospital, St Louis, Missouri
| | - Joan Smith
- Department of Pediatrics, St Louis Children's Hospital, St Louis, Missouri
| | - Doreen Soliman
- Department of Anesthesia, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Natalie Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Margaret Holston
- Department of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Richard McClead
- Department of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Judy Guidash
- Nemours Children's Health System, Wilmington, Delaware
| | - Eugenia K Pallotto
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Missouri-Kansas City and Children's Mercy Kansas City, Missouri
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Woods SD, McElhanon BO, Durham MM, Figueroa J, Piazza AJ. Mucous Fistula Refeeding Promotes Earlier Enteral Autonomy in Infants With Small Bowel Resection. J Pediatr Gastroenterol Nutr 2021; 73:654-658. [PMID: 34347677 DOI: 10.1097/mpg.0000000000003272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Infants requiring intestinal resection because of necrotizing enterocolitis (NEC) or small bowel atresia (SBA) may benefit from mucous fistula refeeding (MFR) of enterostomy output to improve nutrition and bowel adaptation before reanastomosis. Previous series demonstrated improved outcomes with MFR but did not account for varied patient characteristics as potential sources of bias. We performed a cohort analysis using multivariable adjusted models to compare outcomes of patients with and without MFR. METHODS Retrospective chart review was performed for patients with NEC or SBA and small bowel resection with enterostomy and MF. Demographic and outcome data was compared between MFR and non-MFR groups using adjusted multivariable analysis for potential confounding variables. RESULTS MFR was performed in 65 of 101 patients (64%), including 45 of 75 patients with NEC and 20 of 26 patients with SBA. Reasons for not receiving MFR included bowel stricture, technical limitation, or not otherwise specified. NEC patients receiving MFR had 14 fewer days to achieve full enteral feeds after intestinal reconnection, 22 fewer days of parenteral nutrition, lower peak direct bilirubin by 2.4 mg/dL, and 77% less odds of ursodiol use (all P < 0.01). SBA patients had similar trends not reaching statistical significance. Growth parameters were improved in MFR groups. There were no complications or increased infections from MFR. CONCLUSIONS This study suggests that MFR safely improves nutritional outcomes in infants with intestinal resection, related to decreased total parenteral nutrition (TPN) dependence and earlier enteral autonomy.
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Affiliation(s)
- Sean D Woods
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University - Children's Healthcare of Atlanta at Egleston
| | | | | | - Janet Figueroa
- Department of Pediatrics, Pediatrics Biostatistics Core, Emory University School of Medicine, Atlanta, GA
| | - Anthony J Piazza
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University - Children's Healthcare of Atlanta at Egleston
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Brozanski BS, Piazza AJ, Chuo J, Natarajan G, Grover TR, Smith JR, Mingrone T, McClead RE, Rakesh R, Rintoul N, Guidash J, Bellflower B, Holston M, Richardson T, Pallotto EK. STEPP IN: Working Together to Keep Infants Warm in the Perioperative Period. Pediatrics 2020; 145:e20191121. [PMID: 32193210 DOI: 10.1542/peds.2019-1121] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Reduce postoperative hypothermia by up to 50% over a 12-month period in children's hospital NICUs and identify specific clinical practices that impact success. METHODS Literature review, expert opinion, and benchmarking were used to develop clinical practice recommendations for maintaining perioperative euthermia that included the following: established euthermia before transport to the operating room (OR), standardized practice for maintaining euthermia on transport to and from the OR, and standardized practice to prevent intraoperative heat loss. Process measures were focused on maintaining euthermia during these time points. The outcome measure was the proportion of patients with postoperative hypothermia (temperature ≤36°C within 30 minutes of a return to the NICU or at the completion of a procedure in the NICU). Balancing measures were the proportion of patients with postoperative temperature >38°C or the presence of thermal burns. Multivariable logistic regression was used to identify key practices that improved outcome. RESULTS Postoperative hypothermia decreased by 48%, from a baseline of 20.3% (January 2011 to September 2013) to 10.5% by June 2015. Strategies associated with decreased hypothermia include >90% compliance with patient euthermia (36.1-37.9°C) at times of OR arrival (odds ratio: 0.58; 95% confidence interval [CI]: 0.43-0.79; P < .001) and OR departure (odds ratio: 0.0.73; 95% CI: 0.56-0.95; P = .017) and prewarming the OR ambient temperature to >74°F (odds ratio: 0.78; 95% CI: 0.62-0.999; P = .05). Hyperthermia increased from a baseline of 1.1% to 2.2% during the project. No thermal burns were reported. CONCLUSIONS Reducing postoperative hypothermia is possible. Key practices include prewarming the OR and compliance with strategies to maintain euthermia at select time points throughout the perioperative period.
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Affiliation(s)
- Beverly S Brozanski
- Department of Pediatrics, St Louis Children's Hospital and Washington University, and
| | - Anthony J Piazza
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - John Chuo
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Girija Natarajan
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Theresa R Grover
- Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado
| | - Joan R Smith
- Department of Quality, Safety, and Practice Excellence, St Louis Children's Hospital, St Louis, Missouri
| | - Teresa Mingrone
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Richard E McClead
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Rao Rakesh
- Department of Pediatrics, St Louis Children's Hospital and Washington University, and
| | - Natalie Rintoul
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Bobby Bellflower
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Margaret Holston
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Eugenia K Pallotto
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
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Sewell EK, Piazza AJ, Davis J, Heard ML, Figueroa J, Keene SD. Inotrope Needs in Neonates Requiring Extracorporeal Membrane Oxygenation for Respiratory Failure. J Pediatr 2019; 214:128-133. [PMID: 31443896 DOI: 10.1016/j.jpeds.2019.07.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/03/2019] [Accepted: 07/11/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate how inotropic requirements in neonates with respiratory failure are affected by extracorporeal membrane oxygenation (ECMO) mode and whether high requirements predict mortality. STUDY DESIGN This retrospective chart review included all neonates undergoing ECMO for primary respiratory failure from 2010 to 2016 at a single institution. The vasoactive inotropy score (VIS) was calculated as described in the literature. Data were analyzed with descriptive statistics and univariate analyses. RESULTS Of the 110 identified neonates, 96 underwent venovenous (VV) (87%), 11 (10%) venoarterial, and 3 (3%) converted from VV to venoarterial. The median precannulation VIS score was 33.02 for patients who underwent VV compared with 28.93 for venoarterial (P = .25) and 15 for infants converted. VIS decreased dramatically by 4 hours of ECMO in both groups. The VIS before cannulation was similar in survivors and nonsurvivors, but was significantly higher in nonsurvivors after 24 hours of ECMO (median VIS, 12 [IQR, 8-25] vs 8 [IQR, 3.0-14.5]; P = .035) and at decannulation (10 [IQR, 7-19] vs 3 [IQR, 0-7]; P < .001). CONCLUSIONS Neonates with respiratory failure can be successfully managed on VV ECMO even with considerable vasoactive requirements. Vasoactive requirement after 24 hours of ECMO was predictive of mortality.
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Affiliation(s)
- Elizabeth K Sewell
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Division of Neonatology Children's Healthcare of Atlanta, Atlanta, GA; Emory + Children's Pediatric Institute, Atlanta, GA
| | - Anthony J Piazza
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Division of Neonatology Children's Healthcare of Atlanta, Atlanta, GA; Emory + Children's Pediatric Institute, Atlanta, GA
| | - Joel Davis
- ECMO and Advanced Technologies, Children's Healthcare of Atlanta, Atlanta, GA
| | - Micheal L Heard
- ECMO and Advanced Technologies, Children's Healthcare of Atlanta, Atlanta, GA
| | - Janet Figueroa
- Biostatistic Core, Emory + Children's Research Alliance, Atlanta, GA
| | - Sarah D Keene
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Division of Neonatology Children's Healthcare of Atlanta, Atlanta, GA; Emory + Children's Pediatric Institute, Atlanta, GA
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5
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Yanowitz TD, Sullivan KM, Piazza AJ, Brozanski B, Zaniletti I, Sharma J, DiGeronimo R, Nayak SP, Wadhawan R, Reber KM, Murthy K. Does the initial surgery for necrotizing enterocolitis matter? Comparative outcomes for laparotomy vs. peritoneal drain as initial surgery for necrotizing enterocolitis in infants <1000 g birth weight. J Pediatr Surg 2019; 54:712-717. [PMID: 30765157 DOI: 10.1016/j.jpedsurg.2018.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 11/25/2018] [Accepted: 12/12/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Quantify short-term outcomes associated with initial surgery [laparotomy (LAP) vs. peritoneal drain (PD)] for necrotizing enterocolitis (NEC) in extremely-low-birth-weight (ELBW) infants. METHODS Using the Children's Hospitals Neonatal Database, we identified ELBW infants <32 weeks' gestation with surgical NEC (sNEC). Unadjusted and multivariable regression analyses were used to estimate the associations between LAP (or PD) and death/short bowel syndrome (SBS) and length of stay (LOS). RESULTS LAP was the more common initial procedure for sNEC (n = 359/528, 68%). Infants receiving LAP were older and heavier. Initial procedure was unrelated to death/SBS in both bivariate (LAP: 43% vs PD: 46%, p = 0.573) and multivariable analyses (OR = 0.89, 95% CI = 0.57, 1.38, p = 0.6). LAP was inversely related to mortality (29% vs. 41%, p < 0.007) in bivariate analysis, but not significant in multivariable analysis accounting for markers of preoperative illness severity. However, the association between LAP and SBS (14% vs. 5%, p = 0.012) remained significant in multivariable analyses (adjusted OR = 2.25, p = 0.039). LOS among survivors was unrelated to the first surgical procedure in multivariable analysis. CONCLUSION ELBW infants who undergo LAP as the initial operative procedure for sNEC may be at higher risk for SBS without a clear in-hospital survival advantage or shorter hospitalization. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
| | - Kevin M Sullivan
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | | | | | | | - Jotishna Sharma
- University of Missouri Kansas City School of Medicine, Kansas City, MO
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Pallotto EK, Piazza AJ, Smith JR, Grover TR, Chuo J, Provost L, Mingrone T, Holston M, Moran S, Morelli L, Zaniletti I, Brozanski B. Sustaining SLUG Bug CLABSI Reduction: Does Sterile Tubing Change Technique Really Work? Pediatrics 2017; 140:peds.2016-3178. [PMID: 28951441 DOI: 10.1542/peds.2016-3178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To evaluate the ability to sustain and further reduce central line-associated bloodstream infection (CLABSI) rates in NICUs participating in a multicenter CLABSI reduction collaborative and to assess the impact of the sterile tubing change (TC) technique as an important component in CLABSI reduction. METHODS A multi-institutional quality improvement collaborative lowered CLABSI rates in level IV NICUs over a 12-month period. During the 19-month sustain phase, centers were encouraged to monitor and report compliance measures but were only required to report the primary outcome measure of the CLABSI rate. Four participating centers adopted the sterile TC technique during the sustain phase as part of a local Plan-Do-Study-Act cycle. RESULTS The average aggregate baseline NICU CLABSI rate of 1.076 CLABSIs per 1000 line days was sustained for 19 months across 17 level IV NICUs from January 2013 to July 2014. Four centers transitioning from the clean to the sterile TC technique during the sustain phase had a 64% decrease in CLABSI rates from the baseline (1.59 CLABSIs per 1000 line days to 0.57 CLABSIs per 1000 line days). CONCLUSIONS Sustaining low CLABSI rates in a multicenter collaborative is feasible with team engagement and ongoing collaboration. With these results, we further demonstrate the positive impact of the sterile TC technique in CLABSI reduction efforts.
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Affiliation(s)
- Eugenia K Pallotto
- Division of Neonatology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri;
| | - Anthony J Piazza
- Department of Pediatrics, Emory University - Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
| | - Joan R Smith
- Department of Pediatrics, St Louis Children's Hospital, St Louis, Missouri
| | - Theresa R Grover
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - John Chuo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Teresa Mingrone
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Margaret Holston
- Department of Neonatology, Nationwide Children's Hospital, Columbus, Ohio; and
| | | | | | | | | | | | - Beverly Brozanski
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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7
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Navarrete CT, Wrage LA, Carlo WA, Walsh MC, Rich W, Gantz MG, Das A, Schibler K, Newman NS, Piazza AJ, Poindexter BB, Shankaran S, Sánchez PJ, Morris BH, Frantz ID, Van Meurs KP, Cotten CM, Ehrenkranz RA, Bell EF, Watterberg KL, Higgins RD, Duara S. Growth Outcomes of Preterm Infants Exposed to Different Oxygen Saturation Target Ranges from Birth. J Pediatr 2016; 176:62-68.e4. [PMID: 27344218 PMCID: PMC5327617 DOI: 10.1016/j.jpeds.2016.05.070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 03/31/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To test whether infants randomized to a lower oxygen saturation (peripheral capillary oxygen saturation [SpO2]) target range while on supplemental oxygen from birth will have better growth velocity from birth to 36 weeks postmenstrual age (PMA) and less growth failure at 36 weeks PMA and 18-22 months corrected age. STUDY DESIGN We evaluated a subgroup of 810 preterm infants from the Surfactant, Positive Pressure, and Oxygenation Randomized Trial, randomized at birth to lower (85%-89%, n = 402, PMA 26 ± 1 weeks, birth weight 839 ± 186 g) or higher (91%-95%, n = 408, PMA 26 ± 1 weeks, birth weight 840 ± 191 g) SpO2 target ranges. Anthropometric measures were obtained at birth, postnatal days 7, 14, 21, and 28; then at 32 and 36 weeks PMA; and 18-22 months corrected age. Growth velocities were estimated with the exponential method and analyzed with linear mixed models. Poor growth outcome, defined as weight <10th percentile at 36 weeks PMA and 18-22 months corrected age, was compared across the 2 treatment groups by the use of robust Poisson regression. RESULTS Growth outcomes including growth at 36 weeks PMA and 18-22 months corrected age, as well as growth velocity were similar in the lower and higher SpO2 target groups. CONCLUSION Targeting different oxygen saturation ranges between 85% and 95% from birth did not impact growth velocity or reduce growth failure in preterm infants.
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Affiliation(s)
| | - Lisa A. Wrage
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Wade Rich
- Division of Neonatology, University of California San Diego, San Diego, CA
| | - Marie G. Gantz
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Kurt Schibler
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, OH
| | - Nancy S. Newman
- Division of Neonatology, University of California San Diego, San Diego, CA
| | - Anthony J. Piazza
- Emory University School of Medicine, Department of Pediatrics, and Children’s Healthcare of Atlanta, Atlanta, GA
| | - Brenda B. Poindexter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Pablo J. Sánchez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Brenda H. Morris
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX
| | - Ivan D. Frantz
- Department of Pediatrics, Division of Newborn Medicine, Floating Hospital for Children, Tufts Medical Center, Boston, MA
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA
| | | | | | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | | | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Shahnaz Duara
- University of Miami Miller School of Medicine, Miami, FL
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Pallotto EK, Chuo J, Piazza AJ, Provost L, Grover TR, Smith JR, Mingrone T, Moran S, Morelli L, Zaniletti I, Brozanski B. Orchestrated Testing. Am J Med Qual 2016; 32:87-92. [PMID: 26483566 DOI: 10.1177/1062860615609994] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Health care quality improvement collaboratives implement care bundles to target critical parts of a complex system to improve a specific health outcome. The quantitative impact of each component of the care bundle is often unknown. Orchestrated testing (OT) is an application of planned experimentation that allows simultaneous examination of multiple practices (bundle elements) to determine which intervention or combination of interventions affects the outcome. The purpose of this article is to describe the process needed to design and implement OT methodology for improvement collaboratives. Examples from a multicenter collaborative to reduce central line-associated bloodstream infections highlight the practical application of this approach. The key components for implementation of OT are the following: (1) define current practice and evidence, (2) develop a factorial matrix and calculate power, (3) formulate structure for engagement, (4) analyze results, and (5) replicate findings.
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Affiliation(s)
- Eugenia K Pallotto
- 1 Children's Mercy-Kansas City, MO.,2 University of Missouri-Kansas City School of Medicine, MO
| | - John Chuo
- 3 Children's Hospital of Philadelphia, PA.,4 Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Anthony J Piazza
- 5 Children's Healthcare of Atlanta at Egleston, Atlanta, GA.,6 Emory University School of Medicine, Atlanta, GA
| | | | - Theresa R Grover
- 8 Children's Hospital Colorado, Aurora, CO.,9 University of Colorado School of Medicine, Aurora, CO
| | - Joan R Smith
- 10 St Louis Children's Hospital and Goldfarb School of Nursing at Barnes-Jewish College, St Louis, MO
| | - Teresa Mingrone
- 11 Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Lorna Morelli
- 12 Children's Hospital Association, Overland Park, KS
| | | | - Beverly Brozanski
- 11 Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA.,13 University of Pittsburgh School of Medicine, Pittsburgh, PA
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Montague EC, Hilinski JA, Williams HO, McCracken CE, Giannopoulos HT, Piazza AJ. Respiratory Decompensation and Immunization of Preterm Infants. Pediatrics 2016; 137:peds.2015-4225. [PMID: 27244819 DOI: 10.1542/peds.2015-4225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Concern for respiratory decompensation after immunization in premature infants, particularly those with bronchopulmonary dysplasia (BPD), may lead to delayed and altered immunization schedules. METHODS A retrospective cohort of premature infants at <32 weeks' gestational age cared for in a tertiary level 4 NICU and immunized during their hospital stay were evaluated for respiratory decompensation within 72 hours of immunization. Respiratory measurements including change in respiratory support, mean fraction of inspired oxygen, and apnea, bradycardia, and desaturation events were compared between those infants with BPD and those without. The primary outcome was the difference in respiratory decompensation defined as a composite of increased respiratory support or increased fraction of inspired oxygen ≥10% within 72 hours of immunization. RESULTS Of 403 infants admitted to the NICU and immunized, 240 met the study criteria. Of those infants, 172 had a diagnosis of BPD. There was no difference in the primary outcome of respiratory decompensation after immunization between groups (P = .65). There was also no significant difference in apnea, bradycardia, and desaturation events between groups (P = .51). CONCLUSIONS In this cohort, respiratory decompensation requiring clinical intervention after immunization of preterm infants both with and without BPD was uncommon and not significantly different between groups. Consideration for immunization of this vulnerable population should not be delayed out of concern for clinical deterioration.
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Affiliation(s)
- Edwin Clark Montague
- Emory University School of Medicine, Department of Pediatrics, Atlanta, Georgia; and
| | - Joseph A Hilinski
- Emory University School of Medicine, Department of Pediatrics, Atlanta, Georgia; and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Helen O Williams
- Emory University School of Medicine, Department of Pediatrics, Atlanta, Georgia; and Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | | | - Anthony J Piazza
- Emory University School of Medicine, Department of Pediatrics, Atlanta, Georgia; and Children's Healthcare of Atlanta, Atlanta, Georgia
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10
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Piazza AJ, Brozanski B, Provost L, Grover TR, Chuo J, Smith JR, Mingrone T, Moran S, Morelli L, Zaniletti I, Pallotto EK. SLUG Bug: Quality Improvement With Orchestrated Testing Leads to NICU CLABSI Reduction. Pediatrics 2016; 137:peds.2014-3642. [PMID: 26702032 DOI: 10.1542/peds.2014-3642] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Reduce central line-associated bloodstream infection (CLABSI) rates 15% over 12 months in children's hospital NICUs. Use orchestrated testing as an approach to identify important CLABSI prevention practices. METHODS Literature review, expert opinion, and benchmarking were used to develop clinical practice recommendations for central line care. Four existing CLABSI prevention strategies (tubing change technique, hub care monitoring, central venous catheter access limitation, and central venous catheter removal monitoring) were identified for study. We compared the change in CLABSI rates from baseline throughout the study period in 17 participating centers. Using orchestrated testing, centers were then placed into 1 of 8 test groups to identify which prevention practices had the greatest impact on CLABSI reduction. RESULTS CLABSI rates decreased by 19.28% from 1.333 to 1.076 per 1000 line-days. Six of the 8 test groups and 14 of the 17 centers had decreased infection rates; 16 of the 17 centers achieved >75% compliance with process measures. Hub scrub compliance monitoring, when used in combination with sterile tubing change, decreased CLABSI rates by 1.25 per 1000 line-days. CONCLUSIONS This multicenter improvement collaborative achieved a decrease in CLABSI rates. Orchestrated testing identified infection prevention practices that contribute to reductions in infection rates. Sterile tubing change in combination with hub scrub compliance monitoring should be considered in CLABSI reduction efforts.
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Affiliation(s)
- Anthony J Piazza
- Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia; Department of Pediatrics, Emory University, Atlanta, Georgia;
| | - Beverly Brozanski
- Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Theresa R Grover
- Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | - John Chuo
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joan R Smith
- St Louis Children's Hospital, St Louis, Missouri; Goldfarb School of Nursing at Barnes-Jewish College, St Louis, Missouri
| | - Teresa Mingrone
- Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Susan Moran
- Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | - Lorna Morelli
- Children's Hospital Association; Washington, District of Columbia
| | | | - Eugenia K Pallotto
- Children's Mercy Kansas City, Kansas City, Missouri; and Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
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Carlo WA, Finer NN, Walsh MC, Rich W, Gantz MG, Laptook AR, Yoder BA, Faix RG, Das A, Poole WK, Schibler K, Newman NS, Ambalavanan N, Frantz ID, Piazza AJ, Sánchez PJ, Morris BH, Laroia N, Phelps DL, Poindexter BB, Cotten CM, Van Meurs KP, Duara S, Narendran V, Sood BG, O'Shea TM, Bell EF, Ehrenkranz RA, Watterberg KL, Higgins RD. Target ranges of oxygen saturation in extremely preterm infants. N Engl J Med 2010; 362:1959-69. [PMID: 20472937 PMCID: PMC2891970 DOI: 10.1056/nejmoa0911781] [Citation(s) in RCA: 573] [Impact Index Per Article: 40.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Previous studies have suggested that the incidence of retinopathy is lower in preterm infants with exposure to reduced levels of oxygenation than in those exposed to higher levels of oxygenation. However, it is unclear what range of oxygen saturation is appropriate to minimize retinopathy without increasing adverse outcomes. METHODS We performed a randomized trial with a 2-by-2 factorial design to compare target ranges of oxygen saturation of 85 to 89% or 91 to 95% among 1316 infants who were born between 24 weeks 0 days and 27 weeks 6 days of gestation. The primary outcome was a composite of severe retinopathy of prematurity (defined as the presence of threshold retinopathy, the need for surgical ophthalmologic intervention, or the use of bevacizumab), death before discharge from the hospital, or both. All infants were also randomly assigned to continuous positive airway pressure or intubation and surfactant. RESULTS The rates of severe retinopathy or death did not differ significantly between the lower-oxygen-saturation group and the higher-oxygen-saturation group (28.3% and 32.1%, respectively; relative risk with lower oxygen saturation, 0.90; 95% confidence interval [CI], 0.76 to 1.06; P=0.21). Death before discharge occurred more frequently in the lower-oxygen-saturation group (in 19.9% of infants vs. 16.2%; relative risk, 1.27; 95% CI, 1.01 to 1.60; P=0.04), whereas severe retinopathy among survivors occurred less often in this group (8.6% vs. 17.9%; relative risk, 0.52; 95% CI, 0.37 to 0.73; P<0.001). There were no significant differences in the rates of other adverse events. CONCLUSIONS A lower target range of oxygenation (85 to 89%), as compared with a higher range (91 to 95%), did not significantly decrease the composite outcome of severe retinopathy or death, but it resulted in an increase in mortality and a substantial decrease in severe retinopathy among survivors. The increase in mortality is a major concern, since a lower target range of oxygen saturation is increasingly being advocated to prevent retinopathy of prematurity. (ClinicalTrials.gov number, NCT00233324.)
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Piazza AJ. Postasphyxial management of the newborn. Clin Perinatol 1999; 26:749-65, ix. [PMID: 10494477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
In this article, postasphyxial management of the newborn is reviewed. Emphasis is placed on the multisystem approach to complications that can occur in an infant who has sustained significant hypoxia and ischemia. The frequently involved organs are reviewed individually with respect to specific complications that arise secondarily to the initial injury. Depending on the severity of damage to the organ, therapeutic interventions are frequently required; however, medical management is often limited to supportive measures and serial evaluations.
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Affiliation(s)
- A J Piazza
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.
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Abstract
The distribution patterns of extracellular matrix elements were determined to ascertain whether they play a role in the localization of lymphocytes in discrete T-cell, B-cell and dome antigen-processing domains within Peyer's patches. Antibodies against collagen types I, III and IV, laminin and fibronectin were applied to cryosections of mouse Peyer's patches and localized by direct or indirect immunoperoxidase methods. T-cell domains were identified with a monoclonal antibody against Thy-1.2. Labeled reticular fibers in distinctive patterns were more numerous in parafollicular and dome areas than within follicles. Germinal centers contained few such fibers. In parafollicular areas, fibers were oriented predominantly toward follicle domes; their distribution corresponded to T-cell zones and lymphocyte traffic areas, with their orientation being parallel to the migration pathways of lymphocytes from high endothelial venules to the antigen-processing domes. Subepithelial and subendothelial basal laminae were immunopositive for type-IV collagen, laminin and fibronectin. The dome subepithelial basal lamina had pore-like discontinuities through which lymphocytes migrated to and from the epithelium. The correspondence of the distribution patterns of extracellular matrix to specific functional domains of Peyer's patches suggests that this matrix provides a structural framework for lymphocyte migration and localization.
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Affiliation(s)
- A Ohtsuka
- Cell Biology and Aging Section, VA Medical Center, San Francisco, CA
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Owen RL, Piazza AJ, Ermak TH. Ultrastructural and cytoarchitectural features of lymphoreticular organs in the colon and rectum of adult BALB/c mice. Am J Anat 1991; 190:10-8. [PMID: 1984672 DOI: 10.1002/aja.1001900103] [Citation(s) in RCA: 62] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The structure and function of colonic mucosal lymphoid organs remain largely unexplored, especially in the rectum hidden within the pelvic vault. Two-month-old female BALB/c mice were anesthetized, and the entire colon was removed from cecum to anus. Distal colonic patches were then prepared for electron microscopy or were quick-frozen and sectioned for immunoperoxidase localization of B cells and T cell subsets. Aggregated lymphoid follicles were distributed irregularly along the entire colon with an average of 1.4 patches per centimeter of colon length. There were large collections of follicles opposite the ileocecal valve (cecal patches), variable numbers of patches throughout the colon, and at least one patch within 10 mm of the anus (rectal patch). Follicles were adjacent to branching crypts lined by epithelium infiltrated by lymphoid cells and containing few goblet cells. In electron micrographs, M cells were identified by their short, irregular microvilli; intraepithelial lymphoid cells; reduced lysosomal dense bodies; and an expanded tubulovesicular network. Small germinal centers were seen. Cytoarchitectural components of colonic lymphoid follicles and Peyer's patch follicles were remarkably similar, despite differences in surrounding mucosa and luminal microbial exposure. The presence of organized lymphoid tissue with M cells and germinal centers suggests that transepithelial particle transport and antigen recognition can take place in the rectum. Whether such tissue has the capacity for uptake of luminal microorganisms is of particular interest, not only because colonic follicles may be sites for local initiation of immune responses but also because they may be important entry points for systemic infection.
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Affiliation(s)
- R L Owen
- Department of Medicine, University of California, San Francisco
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Daneker GW, Piazza AJ, Steele GD, Mercurio AM. Interactions of human colorectal carcinoma cells with basement membranes. Analysis and correlation with differentiation. Arch Surg 1989; 124:183-7. [PMID: 2916940 DOI: 10.1001/archsurg.1989.01410020053009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The abilities of colorectal carcinoma cell lines to adhere and invade through a basement membrane were examined. The four poorly differentiated cell lines studied were three to four times more adherent and spread to a greater extent following adherence to a basement membrane matrix than the three moderately well-differentiated (MWD) lines. One exception was the MWD cell line DLD-2, whose histologic features resembled a signet ring carcinoma. The ability of these cells to invade through a basement membrane model was measured. This assay showed that the poorly differentiated cell lines as well as DLD-2 were three times more invasive than the remaining MWD cell lines. These data indicate that tumor cell adherence can be correlated with invasion through basement membranes. In addition, the ability of colorectal carcinoma cells to interact with the basement membrane seems, in general, to be inversely related to the degree of cytodifferentiation.
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Affiliation(s)
- G W Daneker
- Laboratory of Cancer Biology, New England Deaconess Hospital, Boston
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Daneker GW, Piazza AJ, Steele GD, Mercurio AM. Relationship between extracellular matrix interactions and degree of differentiation in human colon carcinoma cell lines. Cancer Res 1989; 49:681-6. [PMID: 2910488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Human colon carcinoma cell lines that vary in their degree of differentiation were examined for their ability to interact with extracellular matrix components. For this purpose, established cell lines were classified on the basis of several criteria that relate to degree of differentiation. These criteria include histology of the original tumor, histology of xenografts, in vitro morphology, and carcinoembryonic antigen expression. On this basis, the cell lines used were either moderately well or poorly differentiated. The poorly differentiated cell lines adhered to surfaces coated with laminin or reconstituted basement membrane extract (Matrigel) to a significantly greater extent than the moderately well differentiated lines with the exception of one moderately well differentiated line that was derived from a highly aggressive signet ring cell carcinoma. In addition, the poorly differentiated cell lines exhibited considerable spreading on laminin and Matrigel after adherence that was not evident for the moderately well differentiated lines. The adherence of these cell lines on fibronectin-coated surfaces did not correlate as well with differentiation although, in general, poorly differentiated cell lines adhered better than moderately well differentiated lines. None of the cells that adhered to fibronectin exhibited the extensive spreading seen on laminin. The specificity of tumor cell interactions with extracellular matrix glycoproteins was examined using synthetic peptides which correspond to sequences within these proteins that are recognized by cell surface receptors. The pentapeptide YIGSR-NH2 significantly inhibited the adherence and spreading of the tumor cell lines on laminin, but not on fibronectin. The peptide RGDS, however, did not inhibit tumor cell interactions with laminin although it did inhibit their interactions with fibronectin. Thus, the interactions of colon carcinoma cells with laminin and fibronectin are probably mediated by separate receptors. Taken together, the data demonstrate that cells derived from colon carcinomas exhibit considerable variation in their ability to interact with extracellular matrix components, and that this variability is related to the degree of differentiation of original tumor.
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Affiliation(s)
- G W Daneker
- Laboratory of Cancer Biology, New England Deaconess Hospital, Boston, MA 02115
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