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Gaetani M, Parshuram CS, Redelmeier DA. Furosemide in pediatric intensive care: a retrospective cohort analysis. Front Pediatr 2024; 11:1306498. [PMID: 38293664 PMCID: PMC10824983 DOI: 10.3389/fped.2023.1306498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/21/2023] [Indexed: 02/01/2024] Open
Abstract
Introduction Furosemide is the most commonly used medication in pediatric intensive care. Growing data indicates improved hemodynamic stability and efficacy of furosemide infusions compared to intermittent injections, thereby suggesting furosemide infusions might be considered as first line therapy in critically ill, paediatric patients. The objective of this study is to examine furosemide treatment as either continuous infusions or intermittent injections and subsequent patient outcomes. Methods This is a retrospective cohort analysis of patients treated in a pediatric intensive care unit (ICU) over a nine year period (July 31st 2006 and July 31, 2015). Eligible patients were admitted to either the general pediatric or cardiac specific ICU for a duration of at least 6 hours and who received intravenous furosemide treatment. Results A total of 7,478 patients were identified who received a total of 118,438 furosemide administrations for a total of 113,951 (96%) intermittent doses and 4,487 (4%) infusions running for a total of 1,588,750 hours. A total of 5,996 (80%) patients received exclusively furosemide injections and 1,482 (20%) patients received at least one furosemide infusion. A total of 193 patients died during ICU admission, amounting to 87 (6%) of the 1,482 patients who received an infusion and 106 (2%) of the 5,996 who received intermittent injections. Multivariable regression analysis showed no statistically significant decrease in adjusted mortality for patients who received furosemide injections compared to furosemide infusions (aOR 1.20, CI 0.76-1.89). Discussion This retrospective study observed similar mortality for patients who received furosemide infusions compared to furosemide injections. More research on furosemide in the ICU could provide insights on fluid management, drug effectiveness, and pharmacologic stewardship for critically ill children.
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Affiliation(s)
- Melany Gaetani
- Child Health Evaluative Sciences, The Research Institute Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Center for Safety Research, Toronto, ON, Canada
| | - Christopher S. Parshuram
- Child Health Evaluative Sciences, The Research Institute Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Center for Safety Research, Toronto, ON, Canada
- Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada
| | - Donald A. Redelmeier
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Toronto, ON, Canada
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Dale NM, Ashir GM, Maryah LB, Shepherd S, Tomlinson G, Briend A, Zlotkin S, Parshuram CS. Evaluating the Validity of the Responses to Illness Severity Quantification Score to Discriminate Illness Severity and Level of Care Transitions in Hospitalized Children with Severe Acute Malnutrition. J Pediatr 2023; 262:113609. [PMID: 37419241 DOI: 10.1016/j.jpeds.2023.113609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/25/2023] [Accepted: 06/28/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE To evaluate the validity of the Responses to Illness Severity Quantification (RISQ) score to discriminate illness severity and transitions between levels of care during hospitalization. STUDY DESIGN A prospective observational study conducted in Maiduguri, Nigeria, enrolled inpatients aged 1-59 months with severe acute malnutrition. The primary outcome was the RISQ score associated with the patient state. Heart and respiratory rate, oxygen saturation, respiratory effort, oxygen use, temperature, and level of consciousness are summed to calculate the RISQ score. Five states were defined by levels of care and hospital discharge outcome. The states were classified hierarchically, reflecting illness severity: hospital mortality was the most severe state, then intensive care unit (ICU), care in the stabilization phase (SP), care in the rehabilitation phase (RP), and lowest severity, survival at hospital discharge. A multistate statistical model examined performance of the RISQ score in predicting clinical states and transitions. RESULTS Of 903 children enrolled (mean age, 14.6 months), 63 (7%) died. Mean RISQ scores during care in each phase were 3.5 (n = 2265) in the ICU, 1.7 (n = 6301) in the SP, and 1.5 (n = 2377) in the RP. Mean scores and HRs for a 3-point change in score at transitions: ICU to death, 6.9 (HR, 1.80); SP to ICU, 2.8 (HR, 2.00); ICU to SP, 2.0 (HR, 0.5); and RP to discharge, 1.4 (HR, 0.91). CONCLUSIONS The RISQ score can discriminate between points of escalation or de-escalation of care and reflects illness severity in hospitalized children with severe acute malnutrition. Evaluation of clinical implementation and demonstration of benefit will be important before widespread adoption.
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Affiliation(s)
- Nancy M Dale
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Center for Safety Research, Toronto, ON, Canada; Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Garba Mohammed Ashir
- Department of Pediatrics, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Lawan Bukar Maryah
- Department of Pediatrics, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Susan Shepherd
- Alliance for International Medical Action, Dakar, Senegal
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - André Briend
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland; Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark
| | - Stanley Zlotkin
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Christopher S Parshuram
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Center for Safety Research, Toronto, ON, Canada; Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.
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3
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Maratta C, Hutchison K, Nicoll J, Bagshaw SM, Granton J, Kirpalani H, Stelfox HT, Ferguson N, Cook D, Parshuram CS, Moore GP. Overnight staffing in Canadian neonatal and pediatric intensive care units. Front Pediatr 2023; 11:1271730. [PMID: 38027260 PMCID: PMC10646373 DOI: 10.3389/fped.2023.1271730] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 08/02/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Aim Infants and children who require specialized medical attention are admitted to neonatal and pediatric intensive care units (ICUs) for continuous and closely supervised care. Overnight in-house physician coverage is frequently considered the ideal staffing model. It remains unclear how often this is achieved in both pediatric and neonatal ICUs in Canada. The aim of this study is to describe overnight in-house physician staffing in Canadian pediatric and level-3 neonatal ICUs (NICUs) in the pre-COVID-19 era. Methods A national cross-sectional survey was conducted in 34 NICUs and 19 pediatric ICUs (PICUs). ICU directors or their delegates completed a 29-question survey describing overnight staffing by resident physicians, fellow physicians, nurse practitioners, and attending physicians. A comparative analysis was conducted between ICUs with and without in-house physicians. Results We obtained responses from all 34 NICUs and 19 PICUs included in this study. A total of 44 ICUs (83%) with in-house overnight physician coverage provided advanced technologies, such as extracorporeal life support, and included all ICUs that catered to patients with cardiac, transplant, or trauma conditions. Residents provided the majority of overnight coverage, followed by the Critical Care Medicine fellows. An attending physician was in-house overnight in eight (15%) out of the 53 ICUs, seven of which were NICUs. Residents participating in rotations in the ICU would often have rotation durations of less than 6 weeks and were often responsible for providing care during shifts lasting 20-24 h. Conclusion Most PICUs and level-3 NICUs in Canada have a dedicated in-house physician overnight. These physicians are mainly residents or fellows, but a notable variation exists in this arrangement. The potential effects on patient outcomes, resident learning, and physician satisfaction remain unclear and warrant further investigation.
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Affiliation(s)
- Christina Maratta
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
| | - Kristen Hutchison
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Jessica Nicoll
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - John Granton
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Haresh Kirpalani
- Department of Paediatrics, University of Pennsylvania, Philadelphia, PA, United States
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine and O’Brien Institute for Public Health, University of Calgary & Alberta Health Services, Calgary, AB, Canada
| | - Niall Ferguson
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Physiology, University of Toronto, Toronto, ON, Canada
| | - Deborah Cook
- Department of Medicine and Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
- Division of Critical Care Medicine, McMaster University, Hamilton, ON, Canada
| | - Christopher S. Parshuram
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Gregory P. Moore
- Division of Neonatology, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Newborn Care, The Ottawa Hospital, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Research Unit, Research Institute, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
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Gawronski O, Latour JM, Cecchetti C, Iula A, Ravà L, Ciofi Degli Atti ML, Dall'Oglio I, Tiozzo E, Raponi M, Parshuram CS. Escalation of care in children at high risk of clinical deterioration in a tertiary care children's hospital using the Bedside Pediatric Early Warning System. BMC Pediatr 2022; 22:530. [PMID: 36071513 PMCID: PMC9450425 DOI: 10.1186/s12887-022-03555-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 08/16/2022] [Indexed: 11/30/2022] Open
Abstract
Background Escalation and de-escalation are a routine part of high-quality care that should be matched with clinical needs. The aim of this study was to describe escalation of care in relation to the occurrence and timing of Pediatric Intensive Care Unit (PICU) admission in a cohort of pediatric inpatients with acute worsening of their clinical condition. Methods A monocentric, observational cohort study was performed from January to December 2018. Eligible patients were children: 1) admitted to one of the inpatient wards other than ICU; 2) under the age of 18 years at the time of admission; 3) with two or more Bedside-Paediatric-Early-Warning-System (BedsidePEWS) scores ≥ 7 recorded at a distance of at least one hour and for a period of 4 h during admission. The main outcome -the 24-h disposition – was defined as admission to PICU within 24-h of enrolment or staying in the inpatient ward. Escalation of care was measured using an eight-point scale—the Escalation Index (EI), developed by the authors. The EI was calculated every 6 h, starting from the moment the patient was considered eligible. Analyses used multivariate quantile and logistic regression models. Results The 228 episodes included 574 EI calculated scores. The 24-h disposition was the ward in 129 (57%) and the PICU in 99 (43%) episodes. Patients who were admitted to PICU within 24-h had higher top EI scores [median (IQR) 6 (5–7) vs 4 (3–5), p < 0.001]; higher initial BedsidePEWS scores [median (IQR) 10(8–13) vs. 9 (8–11), p = 0.02], were less likely to have a chronic disease [n = 62 (63%) vs. n = 127 (98%), p < 0.0001], and were rated by physicians as being at a higher risk of having a cardiac arrest (p = 0.01) than patients remaining on the ward. The EI increased over 24 h before urgent admission to PICU or cardiac arrest by 0.53 every 6-h interval (CI 0.37–0.70, p < 0.001), while it decreased by 0.25 every 6-h interval (CI -0.36–0.15, p < 0.001) in patients who stayed on the wards. Conclusion Escalation of care was related to temporal changes in severity of illness, patient background and environmental factors. The EI index can improve responses to evolving critical illness. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03555-0.
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Affiliation(s)
- Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, Rome, Italy.
| | - Jos Maria Latour
- Faculty of Health, School of Nursing and Midwifery, University of Plymouth, Plymouth, UK.,School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, Rome, Italy
| | - Angela Iula
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, Rome, Italy
| | - Lucilla Ravà
- Clinical Epidemiology Unit, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, Rome, Italy
| | | | - Immacolata Dall'Oglio
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, Rome, Italy
| | - Emanuela Tiozzo
- Professional Development, Continuing Education and Research Unit, Medical Directorate, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, Rome, Italy
| | - Massimiliano Raponi
- Medical Directorate, Bambino Gesù Children's Hospital IRCCS, P.zza S. Onofrio 4, Rome, Italy
| | - Christopher S Parshuram
- Paediatric Intensive Care Unit, Critical Care Program, Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G1X8, Canada
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5
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Taylor KL, Frndova H, Szadkowski L, Joffe AR, Parshuram CS. Risk factors for unplanned paediatric intensive care unit admission after anaesthesia—an international multicentre study. Paediatr Child Health 2022; 27:333-339. [DOI: 10.1093/pch/pxac041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Unplanned intensive care unit (ICU) admissions are associated with near-miss events, morbidity, and mortality. We describe the rate, resource utilization, and outcomes of paediatric patients urgently admitted directly to ICU post-anaesthesia compared to other sources of unplanned ICU admissions.
Methods
We performed a secondary analysis of data from specialist paediatric hospitals in 7 countries. Patients urgently admitted to the ICU post-anaesthesia were combined and matched with 1 to 3 unique controls from unplanned ICU admissions from other locations by age and hospital. Demographic, clinical, and outcome variables were compared using the Wilcoxon rank-sum test for continuous variables and chi-square or Fisher’s exact test for categorical variables. The effect of admission sources on binary outcomes was estimated using univariable conditional logistic regression models with stratification by matched set of anaesthesia and non-anaesthesia admission sources.
Results
Most admissions were <1 year of age and for respiratory reasons. Admissions post-anaesthesia were shorter, occurred later in the day, and were more likely to be mechanically ventilated. Admissions post-anaesthesia were less likely to have had a previous ICU admission (4.8% compared to 11%, P=0.032) or PIM ‘high-risk diagnosis’ (9.5% versus 17.2%, P=0.035) but there was no difference in the number of subsequent ICU admissions. There was no difference in the PIM severity of illness score and no mortality difference between the groups.
Conclusions
Young children and respiratory indications dominated unplanned ICU admissions post-anaesthesia, which was more likely later in the day and with mechanical ventilation.
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Affiliation(s)
- Katherine L Taylor
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children , Toronto, Ontario , Canada
- Department of Anesthesia, University of Toronto , Toronto, Ontario , Canada
| | - Helena Frndova
- Department of Critical Care Medicine, Division of Critical Care Medicine, The Hospital for Sick Children , Toronto, Ontario , Canada
| | - Leah Szadkowski
- University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Ari R Joffe
- Division of Critical Care Medicine, Department of Pediatrics, University of Alberta , Edmonton, Alberta , Canada
| | - Christopher S Parshuram
- Department of Critical Care Medicine, Division of Critical Care Medicine, The Hospital for Sick Children , Toronto, Ontario , Canada
- Department of Critical Care Medicine, Department of Paediatrics, University of Toronto , Toronto, Ontario , Canada
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Roumeliotis N, Frndova H, Pullenayegum E, Taddio A, Rochon P, Parshuram CS. Dosing of enteral acetaminophen in critically ill children: a cohort study. Arch Dis Child 2022; 107:388-393. [PMID: 34580057 DOI: 10.1136/archdischild-2021-321952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 09/12/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Acetaminophen is the most common medication prescribed in children's hospitals. The aim of the study was to estimate the frequency and risk factors for acetaminophen underdosing and overdosing in the paediatric intensive care unit (PICU). DESIGN Retrospective cohort of drug administrations in a large tertiary care PICU. PATIENTS All PICU admissions, less than 18 years of age, admitted between 1 January 2008 and 1 January 2018, having received at least one dose of enteral acetaminophen. METHODS The primary outcome was acetaminophen underdosing and overdosing, defined as doses exceeding the 10% upper and lower limits of the standard reference range (10-15 mg/kg) and 10% above daily maximum dose (75 mg/kg). A generalised estimating equation regression assessed patient risk factors for single underdosing, single overdosing and cumulative daily overdosing of acetaminophen. RESULTS Of the 147 485 doses of enteral acetaminophen administered, 7814 (5.3%) were single underdoses (1 in every 19 doses) and 4640 (3.1%) were single overdoses (1 in every 32 doses). There were 6813 cumulative overdose days (1 in every 9 patient-days). Risk factors for both underdosing and overdosing included older age and cardiac admission, whereas risk factors for cumulative overdosing were young age and cardiac admission. Electronic prescribing increased the risk of underdosing and overdosing, but decreased cumulative acetaminophen overdosing (relative risk 0.51, p=0.001). CONCLUSION Acetaminophen underdosing and overdosing are common in the PICU and can be detected with pharmacoepidemiology. Electronic prescribing increased the risk of single underdosing and overdosing, although it reduced the risk of cumulative overdosing.
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Affiliation(s)
- Nadia Roumeliotis
- Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Helena Frndova
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Anna Taddio
- Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paula Rochon
- Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Women's College Hospital, Toronto, Ontario, Canada
| | - Christopher S Parshuram
- Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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Gray SB, Dryden-Palmer K, He C, Tremblay C, Marsot-Schiffman L, Huyer D, Parshuram CS. Severe illness getting noticed sooner: SIGNS-for-Kids-initial validity assessment of a paediatric illness recognition tool for caregivers. BMJ Open Qual 2022; 11:bmjoq-2021-001664. [PMID: 35301184 PMCID: PMC8932283 DOI: 10.1136/bmjoq-2021-001664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 03/06/2022] [Indexed: 11/04/2022] Open
Affiliation(s)
- Seth Bernard Gray
- Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Paediatrics and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Center for Safety Research, SickKids, Toronto, Ontario, Canada
| | - Karen Dryden-Palmer
- Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Center for Safety Research, SickKids, Toronto, Ontario, Canada
| | - Calvin He
- Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Center for Safety Research, SickKids, Toronto, Ontario, Canada
| | - Ciara Tremblay
- Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Center for Safety Research, SickKids, Toronto, Ontario, Canada
| | - Leah Marsot-Schiffman
- Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,Center for Safety Research, SickKids, Toronto, Ontario, Canada
| | - Dirk Huyer
- Office of the Chief Coroner of Ontario, Toronto, Ontario, Canada
| | - Christopher S Parshuram
- Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada .,Paediatrics and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Center for Safety Research, SickKids, Toronto, Ontario, Canada.,Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Ontario, Canada
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8
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Parshuram CS, Cunningham T. Being Present After Pediatric Critical Illness-Home and Hospital, School and Work. JAMA Netw Open 2021; 4:e2140902. [PMID: 34940872 DOI: 10.1001/jamanetworkopen.2021.40902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Christopher S Parshuram
- Paediatric Intensive Care Unit, Critical Care Program, Hospital for Sick Children, Toronto, Canada
- Child Health Evaluative Sciences, The Research Institute, SickKids, Toronto, Canada
- Paediatrics, Critical Care Medicine, Health Policy Management and Evaluation, Center for Patient Safety, University of Toronto, Toronto, Canada
| | - Todd Cunningham
- School and Clinical Child Psychology Program, Department of Applied Psychology and Human Development, University of Toronto-Ontario Institute for Studies in Education, Toronto, Canada
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9
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Dryden-Palmer KD, Parshuram CS, Berta WB. Context, complexity and process in the implementation of evidence-based innovation: a realist informed review. BMC Health Serv Res 2020; 20:81. [PMID: 32013977 PMCID: PMC6998254 DOI: 10.1186/s12913-020-4935-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 01/27/2020] [Indexed: 11/17/2022] Open
Abstract
Background This review of scholarly work in health care knowledge translation advances understanding of implementation components that support the complete and timely integration of new knowledge. We adopt a realist approach to investigate what is known from the current literature about the impact of, and the potential relationships between, context, complexity and implementation process. Methods Informed by two distinct pathways, knowledge utilization and knowledge translation, we utilize Rogers’ Diffusion of Innovations theory (DOI) and Harvey and Kitson’s integrated- Promoting Action on Research Implementation in Health Service framework (PARIHS) to ground this review. Articles from 5 databases; Medline, Scopus, PsycInfo, Web of Science, and Google Scholar and a search of authors were retrieved. Themes and patterns related to these implementation components were extracted. Literature was selected for inclusion by consensus. Data extraction was iterative and was moderated by the authors. Results A total of 67 articles were included in the review. Context was a central component to implementation. It was not clear how and to what extent context impacted implementation. Complexity was found to be a characteristic of context, implementation process, innovations and a product of the relationship between these three elements. Social processes in particular were reported as influential however; descriptions of how these social process impact were limited. Multiple theoretical and operational models were found to ground implementation processes. We offer an emerging conceptual model to illustrate the key discoveries. Conclusions The review findings indicate there are dynamic relationship between context, complexity and implementation process for enhancing uptake of evidence-based knowledge in hospital settings. These are represented in a conceptual model. Limited empiric evidence was found to explain the nature of the relationships.
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Affiliation(s)
- K D Dryden-Palmer
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada. .,Critical Care Program, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Canada. .,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada.
| | - C S Parshuram
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Critical Care Program, The Hospital for Sick Children, 555 University Avenue, Toronto, M5G 1X8, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - W B Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Gilleland J, Bayfield D, Bayliss A, Dryden-Palmer K, Fawcett-Arsenault J, Gordon M, Hartfield D, Iacolucci A, Jones M, Ladouceur L, McNamara M, Middaugh K, Moore G, Murray S, Noble J, Singh S, Stuart-Minaret J, Williams C, Parshuram CS. Severe illness getting noticed sooner - SIGNS-for-Kids: developing an illness recognition tool to connect home and hospital. BMJ Open Qual 2019; 8:e000763. [PMID: 31803854 PMCID: PMC6887512 DOI: 10.1136/bmjoq-2019-000763] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/09/2019] [Accepted: 11/01/2019] [Indexed: 11/27/2022] Open
Abstract
Background Delays to definitive treatment for time-sensitive acute paediatric illnesses continue to be a cause of death and disability in the Canadian healthcare system. Our aim was to develop the SIGNS-for-Kids illness recognition tool to empower parents and other community caregivers to recognise the signs and symptoms of severe illness in infants and children. The goal of the tool is improved detection and reduced time to treatment of acute conditions that require emergent medical attention. Methods A single-day consensus workshop consisting of a 17-member panel of parents and multidisciplinary healthcare experts with content expertise and/or experience managing children with severe acute illnesses was held. An a priori agreement of ≥85% was planned for the final iteration SIGNS-for-Kids tool elements by the end of the workshop. Results One hundred percent consensus was achieved on a five-item tool distilled from 20 initial items at the beginning of the consensus workshop. The final items included four child-based items consisting of: (1) behaviour, (2) breathing, (3) skin, and (4) fluids, and one context-based item and (5) response to rescue treatments. Conclusions Specific cues of urgent child illness were identified as part of this initial development phase. These cues were integrated into a comprehensive tool designed for parents and other lay caregivers to recognise the signs of serious acute illness and initiate medical attention in an undifferentiated population of infants and children. Future validation and optimisation of the tool are planned.
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Affiliation(s)
- Jonathan Gilleland
- Department of Pediatrics, Section of Pediatric Intensive Care Medicine, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - David Bayfield
- Department of Emergency Medicine, Georgian Bay General Hospital, Midland, Ontario, Canada
| | - Ann Bayliss
- Children's Health Division, Trillium Health Partners, Mississauga, Ontario, Canada.,Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Karen Dryden-Palmer
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Michelle Gordon
- Department of Neonatal and Pediatric Medicine, Orillia Soldiers Memorial Hospital, Orillia, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Dawn Hartfield
- Department of Pediatrics, Division of Pediatrics, Hospital Medicine Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Anthony Iacolucci
- Acute Care Transport Services (ACTS), Hospital for Sick Children, Toronto, Ontario, Canada
| | - Melissa Jones
- SickKids Foundation, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lisa Ladouceur
- Nurse Practitioner Clinic, Georgian Bay General Hospital, Midland, Ontario, Canada
| | - Martin McNamara
- Department of Emergency Medicine, Georgian Bay General Hospital, Midland, Ontario, Canada
| | - Kristen Middaugh
- Paediatric Critical Care Medicine, Center for Safety Research, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gregory Moore
- Department of Obstetrics and Gynecology, Division of Newborn Care, Ottawa Hospital General Campus, Ottawa, Ontario, Canada.,Department of Pediatrics, Division of Neonatology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sean Murray
- NEO Kids and Family Program, Health Sciences North, Sudbury, Ontario, Canada
| | - Joanna Noble
- Healthcare Insurance Reciprocal of Canada, Lead Clinical Risk, Healthcare Safety and Risk Management, Toronto, Ontario, Canada
| | - Simran Singh
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jane Stuart-Minaret
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carla Williams
- Canadian Patient Safety Institute, Ottawa, Ontario, Canada
| | - Christopher S Parshuram
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Pediatrics, Critical Care, Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
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11
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Tomasi JN, Hamilton MV, Fan M, Pinkney SJ, Middaugh KL, Parshuram CS, Trbovich PL. Assessing the electronic Bedside Paediatric Early Warning System: A simulation study on decision-making and usability. Int J Med Inform 2019; 133:103969. [PMID: 31765879 DOI: 10.1016/j.ijmedinf.2019.103969] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/22/2019] [Accepted: 09/11/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Bedside Paediatric Early Warning System (BedsidePEWS) is a clinical decision support tool designed to augment clinician expertise, objectively identify children at risk for clinical deterioration, and standardize and prioritize care to improve outcomes in community settings. Although the paper-based BedsidePEWS documentation record has been shown to improve clinicians' perception of their ability to detect deterioration and follow care recommendations, research is needed to asses this impact empirically. Furthermore, as hospitals progressively move toward electronic clinical systems, knowledge regarding the impact of BedsidePEWS' novel electronic interface on clinicians' performance and user experience is required. OBJECTIVES The primary objectives of this study were (1) to compare adherence to evidence-based care recommendations using a) electronic health record software, b) paper BedsidePEWS, and c) a novel electronic BedsidePEWS interface, and (2) to describe end-users' experiences of usability and opportunities for improvement of both paper and electronic BedsidePEWS. METHODS Paediatric nurses participated in a repeated measures simulation study. Participants assessed simulated patients, documented patient data, and responded to a series of questions regarding follow-up care for each patient. Three patient types (i.e., stable, mild deterioration, severe deterioration) were assessed in each of three intervention conditions (i.e., electronic health record, paper BedsidePEWS, electronic BedsidePEWS). Following simulation scenarios, participants provided comments regarding the usability of the paper and electronic tools. RESULTS Participants made 12.7% and 18.0% more appropriate care decisions with paper and electronic BedsidePEWS, respectively, than with the electronic health record intervention (p < 0.001). Accurate BedsidePEWS severity of illness score calculation was related to better adherence to evidence-based care recommendations (65%), compared to inaccurate calculation (55%), and electronic BedsidePEWS was associated with 15.7% fewer calculation errors than paper (p < 0.005). Electronic BedsidePEWS demonstrated usability benefits over its paper predecessor, including automatic score calculation and data plotting, and the potential to eliminate double charting, and participants expressed a preference for electronic BedsidePEWS in all aspects of the debrief questionnaire (p < 0.001). CONCLUSIONS BedsidePEWS in both paper and electronic formats significantly improved participants' ability to detect deterioration and follow care recommendations compared to electronic health record software. Furthermore, results suggest that electronic BedsidePEWS would afford improved patient care in excess of the paper-based original and further contribute to the standardization, prioritization, and improvement of care in community settings.
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Affiliation(s)
- Jessica N Tomasi
- HumanEra, Office of Research and Innovation, North York General Hospital, 4001 Leslie Street, LE-140, North York, ON, Canada.
| | - Megan V Hamilton
- HumanEra, Office of Research and Innovation, North York General Hospital, 4001 Leslie Street, LE-140, North York, ON, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto; 164 College St, Toronto, ON, Canada.
| | - Mark Fan
- HumanEra, Office of Research and Innovation, North York General Hospital, 4001 Leslie Street, LE-140, North York, ON, Canada.
| | - Sonia J Pinkney
- Institute of Health Policy, Management, and Evaluation, University of Toronto; 155 College Street, Toronto, ON, Canada.
| | - Kristen L Middaugh
- Centre for Safety Research, The Hospital for Sick Children; 555 University Avenue, Toronto, ON, Canada.
| | - Christopher S Parshuram
- Institute of Health Policy, Management, and Evaluation, University of Toronto; 155 College Street, Toronto, ON, Canada; Centre for Safety Research, The Hospital for Sick Children; 555 University Avenue, Toronto, ON, Canada.
| | - Patricia L Trbovich
- HumanEra, Office of Research and Innovation, North York General Hospital, 4001 Leslie Street, LE-140, North York, ON, Canada; Institute of Biomaterials and Biomedical Engineering, University of Toronto; 164 College St, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto; 155 College Street, Toronto, ON, Canada.
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12
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Tijssen JA, Miller MR, Parshuram CS. Remote Pediatric Critical Care Telephone Consultations: Quality and Outcomes. J Pediatr Intensive Care 2019; 8:148-155. [PMID: 31404270 PMCID: PMC6687452 DOI: 10.1055/s-0039-1679900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 01/13/2019] [Indexed: 10/27/2022] Open
Abstract
There are no studies describing the nature and quality of telephone consultations for critically ill children despite being an important part of pediatric intensive care. We described pediatric telephone consultations to a PICU in Ontario, Canada in 2011 and 2012. Of 203 consultations, 104 patients (51.2%) were admitted to the PICU; this was associated with weekend consultations ( p = 0.005) and referral hospital location ( p = 0.036). Frequency of interruptions was 1 in every 3.2 (2.0, 5.7) minutes and not associated with call content. Twenty-one percent of consults had limited discussion of vital signs. Our study described our center's remote critical care consultation program and outcomes.
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Affiliation(s)
- Janice A. Tijssen
- Department of Paediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Children's Health Research Institute, London, Ontario, Canada
| | - Michael R. Miller
- Department of Paediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Children's Health Research Institute, London, Ontario, Canada
| | - Christopher S. Parshuram
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- The Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
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13
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Mtaweh H, Soto Aguero MJ, Campbell M, Allard JP, Pencharz P, Pullenayegum E, Parshuram CS. Systematic review of factors associated with energy expenditure in the critically ill. Clin Nutr ESPEN 2019; 33:111-124. [PMID: 31451246 DOI: 10.1016/j.clnesp.2019.06.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/28/2019] [Accepted: 06/17/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Indirect calorimetry is the reference standard for energy expenditure measurement. Predictive formulae that replace it are inaccurate. Our aim was to review the patient and clinical factors associated with energy expenditure in critically ill patients. METHODS We conducted a systematic review of the literature. Eligible studies were those reporting an evaluation of factors and energy expenditure. Energy expenditure and factor associations with p-values were extracted from each study, and each factor was classified as either significantly, indeterminantly, or not associated with energy expenditure. Regression coefficients were summarized as measures of central tendency and spread. Metanalysis was performed on correlations. RESULTS The search strategy yielded 8521 unique articles, 307 underwent full text review, and 103 articles were included. Most studies were in adults. There were 95 factors with 352 evaluations. Minute volume, weight, age, % body surface area burn, sedation, post burn day, and caloric intake were significantly associated with energy expenditure. Heart rate, fraction of inspired oxygen, respiratory rate, respiratory disease diagnosis, positive end expiratory pressure, intensive care unit days, C- reactive protein, and size were not associated with energy expenditure. Multiple factors (n = 37) were identified with an unclear relationship with energy expenditure and require further evaluation. CONCLUSIONS An important interval step in the development of accurate formulae for energy expenditure estimation is a better understanding of relationships between patient and clinical factors and energy expenditure. The review highlights the limitations of currently available data, and identifies important factors that are not included in current prediction formulae of the critically ill.
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Affiliation(s)
- Haifa Mtaweh
- Division of Critical Care, Department of Paediatrics, Hospital for Sick Children, 555 University Ave, Toronto M5G 1X8, Canada; Child Health and Evaluative Sciences, Hospital for Sick Children Research Institute, 686 Bay Street, Toronto M5G 0A4, Canada.
| | - Maria Jose Soto Aguero
- Division of Critical Care, Hospital Nacional de Niños "Carlos Saenz Herrera", Calle 20, Avenida 0, Paseo Colón, San José, Costa Rica
| | - Marla Campbell
- Child Health and Evaluative Sciences, Hospital for Sick Children Research Institute, 686 Bay Street, Toronto M5G 0A4, Canada
| | - Johane P Allard
- Department of Medicine, Toronto General Hospital, University of Toronto, 200 Elizabeth St, Toronto M5G 2C4, Canada
| | - Paul Pencharz
- Department of Paediatrics and Nutritional Sciences, University of Toronto, 1 King's College Circle, Toronto M5S 1A8, Canada
| | - Eleanor Pullenayegum
- Child Health and Evaluative Sciences, Hospital for Sick Children Research Institute, 686 Bay Street, Toronto M5G 0A4, Canada
| | - Christopher S Parshuram
- Division of Critical Care, Department of Paediatrics, Hospital for Sick Children, 555 University Ave, Toronto M5G 1X8, Canada; Child Health and Evaluative Sciences, Hospital for Sick Children Research Institute, 686 Bay Street, Toronto M5G 0A4, Canada
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14
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Mtaweh H, Garros C, Ashkin A, Tuira L, Allard JP, Pencharz P, Pullenayegum E, Joffe A, Parshuram CS. An Exploratory Retrospective Study of Factors Affecting Energy Expenditure in Critically Ill Children. JPEN J Parenter Enteral Nutr 2019; 44:507-515. [PMID: 31267545 DOI: 10.1002/jpen.1673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/31/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Accurate measurement of energy expenditure is not widely available. Patient and clinical factors associated with energy expenditure have been poorly explored, leading to errors in estimation formulae. The objective of this study was to determine clinical factors associated with measured energy expenditure (MEE), expressed in kcal/kg/d, in critically ill children. METHODS This was a retrospective study at 2 Canadian pediatric intensive care units (ICUs). Patients were mechanically ventilated children who had 1 or more MEE using indirect calorimetry. Associations between MEE and 28 clinical factors were evaluated in univariate regression and 16 factors in a multivariate regression model accounting for repeated measurements. RESULTS Data from 239 patients (279 measurements) were analyzed. Median (Q1, Q3) MEE was 34.8 (26.8, 46.2) kcal/kg/d. MEE was significantly associated with weight, heart rate, diastolic blood pressure, ICU day of indirect calorimetry (P = 0.004), minute ventilation, vasoactive inotropic score (P = 0.004), opioids, chloral hydrate, dexmedetomidine, inhaled salbutamol (P = 0.02), and propofol dose (all P < 0.0001 unless otherwise specified) in the final multivariate regression model. CONCLUSIONS This study demonstrated association between MEE (kcal/kg/d) and factors not previously explored in pediatric critical illness. Further evaluation of these factors to confirm associations and more precisely quantify the magnitude of effect is required to support refinement of formulae to estimate energy expenditure.
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Affiliation(s)
- Haifa Mtaweh
- Department of Pediatrics, Division of Critical Care, The Hospital for Sick Children, Toronto, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
| | | | - Allison Ashkin
- Department of Dietetics, Stollery Children's Hospital, Edmonton, Canada
| | - Lori Tuira
- Department of Dietetics, The Hospital for Sick Children, Toronto, Canada
| | - Johane P Allard
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Paul Pencharz
- Department of Paediatrics and Nutritional Sciences, University of Toronto, Toronto, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Ari Joffe
- Department of Pediatrics, Division of Critical Care, Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Christopher S Parshuram
- Department of Pediatrics, Division of Critical Care, The Hospital for Sick Children, Toronto, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Canada
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15
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Tijssen JA, To T, Morrison LJ, Alnaji F, MacDonald RD, Cupido C, Lee KS, Parshuram CS. Paediatric health care access in community health centres is associated with survival for critically ill children who undergo inter-facility transport: A province-wide observational study. Paediatr Child Health 2019; 25:308-316. [PMID: 32765167 DOI: 10.1093/pch/pxz013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 10/28/2018] [Indexed: 11/13/2022] Open
Abstract
Background Diverse settlement makes inter-facility transport of critically ill children a necessary part of regionalized health care. There are few studies of outcomes and health care services use of this growing population. Methods A retrospective study evaluated the frequency of transports, health care services use, and outcomes of all critically ill children who underwent inter-facility transport to a paediatric intensive care unit (PICU) in Ontario from 2004 to 2012. The primary outcome was PICU mortality. Secondary outcomes were 24-hour and 6-month mortality, PICU and hospital lengths of stay, and use of therapies in the PICU. Results The 4,074 inter-facility transports were for children aged median (IQR) 1.6 (0.1 to 8.3) years. The rate of transports increased from 15 to 23 per 100,000 children. There were 233 (5.7%) deaths in PICU and an additional 78 deaths (1.9%) by 6 months. Length of stay was median (IQR) 2 (1 to 5) days in PICU and 7 (3 to 14) days in the receiving hospital. Lower PICU mortality was independently associated with prior acute care contact (odds ratio [OR]=0.3, 95% confidence interval [CI]: 0.2 to 0.6) and availability of paediatric expertise at the referral hospital (OR=0.7, 95% CI: 0.5 to 1.0). Conclusions We found that in Ontario, children undergoing inter-facility transport to PICUs are increasing in number, consume significant acute care resources, and have a high PICU mortality. Access to paediatric expertise is a potentially modifiable factor that can impact mortality and warrants further evaluation.
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Affiliation(s)
- Janice A Tijssen
- Department of Paediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario
| | - Teresa To
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario
| | - Laurie J Morrison
- Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario.,Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario
| | - Fuad Alnaji
- Division of Critical Care Medicine, Department of Paediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Ornge Transport Medicine, Mississauga, Ontario
| | - Russell D MacDonald
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario.,Ornge Transport Medicine, Mississauga, Ontario
| | | | - Kyong-Soon Lee
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario.,Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Christopher S Parshuram
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario.,Department of Paediatrics, University of Toronto, Toronto, Ontario.,Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario
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16
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Parshuram CS, Dryden-Palmer K. The authors reply. Pediatr Crit Care Med 2019; 20:93-94. [PMID: 30614980 DOI: 10.1097/pcc.0000000000001773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Christopher S Parshuram
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada Hospital for Sick Children, Toronto, ON, Canada
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17
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Parshuram CS, Dryden-Palmer K, Farrell C, Gottesman R, Gray M, Hutchison JS, Helfaer M, Hunt EA, Joffe AR, Lacroix J, Moga MA, Nadkarni V, Ninis N, Parkin PC, Wensley D, Willan AR, Tomlinson GA. Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients: The EPOCH Randomized Clinical Trial. JAMA 2018; 319:1002-1012. [PMID: 29486493 PMCID: PMC5885881 DOI: 10.1001/jama.2018.0948] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE There is limited evidence that the use of severity of illness scores in pediatric patients can facilitate timely admission to the intensive care unit or improve patient outcomes. OBJECTIVE To determine the effect of the Bedside Paediatric Early Warning System (BedsidePEWS) on all-cause hospital mortality and late admission to the intensive care unit (ICU), cardiac arrest, and ICU resource use. DESIGN, SETTING, AND PARTICIPANTS A multicenter cluster randomized trial of 21 hospitals located in 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) that provided inpatient pediatric care for infants (gestational age ≥37 weeks) to teenagers (aged ≤18 years). Participating hospitals had continuous physician staffing and subspecialized pediatric services. Patient enrollment began on February 28, 2011, and ended on June 21, 2015. Follow-up ended on July 19, 2015. INTERVENTIONS The BedsidePEWS intervention (10 hospitals) was compared with usual care (no severity of illness score; 11 hospitals). MAIN OUTCOMES AND MEASURES The primary outcome was all-cause hospital mortality. The secondary outcome was a significant clinical deterioration event, which was defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates. RESULTS Among 144 539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144 539 patients (100%) completed the trial. All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with BedsidePEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95% CI, -0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95% CI, 0.61 to 1.69]; P = .96). Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with BedsidePEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, -0.34 [95% CI, -0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95% CI, 0.61 to 0.97]; P = .03). CONCLUSIONS AND RELEVANCE Implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients. These findings do not support the use of this system to reduce mortality. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01260831.
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Affiliation(s)
- Christopher S. Parshuram
- Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Ontario, Canada
- Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Karen Dryden-Palmer
- Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Ontario, Canada
- Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada
| | - Catherine Farrell
- Division of Pediatric Intensive Care, Centre Hospitalier Universitaire de Ste-Justine, Montreal, Quebec, Canada
| | | | - Martin Gray
- Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Neuroscience and Mental Health Research Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - James S. Hutchison
- Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Neuroscience and Mental Health Research Program, SickKids Research Institute, Toronto, Ontario, Canada
| | - Mark Helfaer
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Ari R. Joffe
- Stollery Children’s Hospital, University of Alberta, Edmonton, Canada
| | - Jacques Lacroix
- Division of Pediatric Intensive Care, Centre Hospitalier Universitaire de Ste-Justine, Montreal, Quebec, Canada
| | - Michael Alice Moga
- Critical Care Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Vinay Nadkarni
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nelly Ninis
- St Mary’s Imperial Healthcare, London, England
| | - Patricia C. Parkin
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Wensley
- British Columbia Children’s Hospital, Vancouver, Canada
| | - Andrew R. Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Canada
| | - George A. Tomlinson
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network and Mt Sinai Hospital, Toronto, Ontario, Canada
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Abstract
Measurement of energy expenditure is important in order to determine basal metabolic rate and inform energy prescription provided. Indirect calorimetry is the reference standard and clinically recommended means to measure energy expenditure. This article reviews the historical development, technical, and logistic challenges of indirect calorimetry measurement, and provides case examples for practicing clinicians. Formulae to estimate energy expenditure are highly inaccurate and reinforce the role of the indirect calorimetry and the importance of understanding the strength and limitation of the method and its application.
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Affiliation(s)
- Haifa Mtaweh
- Department of Critical Care Medicine, The Hospital for Sick Children, University Ave, Toronto, ON, Canada
| | - Lori Tuira
- Department of Clinical Dietetics, The Hospital for Sick Children, University Ave, Toronto, ON, Canada
| | - Alejandro A Floh
- Department of Critical Care Medicine, The Hospital for Sick Children, University Ave, Toronto, ON, Canada
| | - Christopher S Parshuram
- Department of Critical Care Medicine, The Hospital for Sick Children, University Ave, Toronto, ON, Canada
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19
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Al-Abdwani R, Williams CB, Dunn C, Macartney J, Wollny K, Frndova H, Chin N, Stephens D, Parshuram CS. Incidence, outcomes and outcome prediction of unplanned extubation in critically ill children: An 11year experience. J Crit Care 2017; 44:368-375. [PMID: 29289914 DOI: 10.1016/j.jcrc.2017.12.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 11/06/2017] [Accepted: 12/22/2017] [Indexed: 12/27/2022]
Abstract
PURPOSE Unplanned extubation represents loss of control in the ICU, is associated with harm and is used as a measure of quality of care. We evaluated the rates and consequences of unplanned extubation. MATERIALS AND METHODS Eligible patients were intubated, <18years, and in ICU. Patient, care-related and environmental characteristics were compared in patients who did and did not receive positive pressure ventilation in the 24h after events. Rates are expressed per 100 intubation-days. RESULTS The 11,310 eligible patient-admissions identified were intubated for 75,519days; 410 (3.39%) patients had 458 unplanned extubation events (0.61 events/100 intubation-days). Annual rates of unplanned extubation reduced from 0.98 in 2004 to 0.37 in 2014. Consequences occurred in 245 (53.5%) events and included cardiac arrest in 9 (2%), bradycardia 52 (11%), and stridor 63 (14%). Positive pressure was provided after 263 (57%) events, and was independently associated with pre-event sedative and muscle relaxant drugs, non-use of restraints, respiratory reason for intubation and recent care by more nurses. CONCLUSION Unplanned extubation was associated with both significant and no morbidity. Modification of factors including more consistent nurse staffing, restraint use, and increased vigilance in patients with previous events may potentially reduce rates and adverse consequences of unplanned extubation.
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Affiliation(s)
- R Al-Abdwani
- Centre for Safety Research, Department of Critical Care Medicine, Hospital for Sick Children, Canada
| | - C B Williams
- Centre for Safety Research, Department of Critical Care Medicine, Hospital for Sick Children, Canada
| | - C Dunn
- Critical Care Program, Hospital for Sick Children, Canada
| | - J Macartney
- Critical Care Program, Hospital for Sick Children, Canada
| | - K Wollny
- Critical Care Program, Hospital for Sick Children, Canada
| | - H Frndova
- Centre for Safety Research, Critical Care Program, Hospital for Sick Children, Canada
| | - N Chin
- Critical Care Program, Informatics, Hospital for Sick Children, Canada
| | - D Stephens
- Child Health and Evaluation Sciences Program, The Research Institute, Hospital for Sick Children, Canada
| | - C S Parshuram
- Department of Critical Care Medicine, Department of Paediatrics, Child Health and Evaluation Sciences Program, The Research Institute, Centre for Safety Research Hospital for Sick Children, Canada; Department of Pediatrics, Interdepartmental Division of Critical Care Medicine, Department of Health Policy Management and Evaluation, University of Toronto, Canada.
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Parshuram CS. Intensive Care Unit Physician Discretion in Pediatric Critical Care. Polarized, Evaluated, and Reframed. Am J Respir Crit Care Med 2017; 194:1443-1444. [PMID: 27976943 DOI: 10.1164/rccm.201606-1309ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Slater MB, Gruneir A, Rochon PA, Howard AW, Koren G, Parshuram CS. Identifying High-Risk Medications Associated with Acute Kidney Injury in Critically Ill Patients: A Pharmacoepidemiologic Evaluation. Paediatr Drugs 2017; 19:59-67. [PMID: 27943125 DOI: 10.1007/s40272-016-0205-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [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] [Indexed: 12/20/2022]
Abstract
BACKGROUND Nephrotoxic medications are a common cause of acute kidney injury (AKI). Critically ill children receive more medication than other inpatients; however, the risk of nephrotoxic medication-induced AKI in these children is not well understood. OBJECTIVE The aim of this study was to determine the association between exposure to nephrotoxic medications in the intensive care unit (ICU) and the development of AKI amongst critically ill children, adjusting for differences in underlying risk. METHODS We conducted a nested case-control study among a cohort of patients admitted to a paediatric intensive care unit between January 2006 and June 2009. Cases were identified according to the RIFLE criteria. Using incidence density sampling, controls were matched 1:1 according to pre-ICU nephrotoxic drug exposure. Administration of nephrotoxic medications and other known risk factors of AKI were evaluated during the ICU stay prior to the diagnosis of AKI. RESULTS A total of 914 patients in the cohort developed AKI and had an identifiable matched control. Eighty-seven percent of cases and 74% of controls were exposed to one or more nephrotoxic medications in the ICU during the study period. Furosemide (administered to 67.8% of patients), vancomycin (28.7%), and gentamicin (21.4%) were the most frequently administered nephrotoxic drugs. Patients who developed AKI were more likely to be exposed to at least one nephrotoxic medication and risk increased with increasing number of nephrotoxic medications. Ganciclovir (adjusted odds ratio [AOR] 4.7; 95% CI 1.7-13.0), furosemide (AOR 1.9; 95% CI 1.4-2.4), and gentamicin (AOR 1.8; 95% CI 1.4-2.4) significantly increased the odds of developing AKI after adjusting for underlying differences in risk factors of AKI. CONCLUSION This is the first study to assess the association between risk-adjusted nephrotoxic medication exposure and the development of AKI in critically ill children. Nephrotoxic medication exposure was common amongst children in the ICU and we found AKI was associated with the administration of specific drugs after adjustment for important risk factors.
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Affiliation(s)
- Morgan B Slater
- Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Andrea Gruneir
- Department of Family Medicine, University of Alberta, Edmonton, AB, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Paula A Rochon
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrew W Howard
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Gideon Koren
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Christopher S Parshuram
- Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada. .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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22
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Taylor KL, Parshuram CS, Ferri S, Mema B. A description of the "event manager" role in resuscitations: A qualitative study of interviews and focus groups of resuscitation participants. J Crit Care 2016; 39:254-258. [PMID: 28082053 DOI: 10.1016/j.jcrc.2016.12.015] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 11/05/2016] [Accepted: 12/15/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE Communication during resuscitation is essential for the provision of coordinated, effective care. Previously, we observed 44% of resuscitation communication originated from participants other than the physician team leader; 65% of which was directed to the team, exclusive of the team leader. We called this outer-loop communication. METHODS This institutional review board-approved qualitative study used grounded theory analysis of focus groups and interviews to describe and define outer-loop communication and the role of "event manager" as an additional "leader." Participants were health care staff involved in the medical management of resuscitations in a quaternary pediatric academic hospital. RESULTS The following 3 domains were identified: the existence and rationale of outer-loop communication; the functions fulfilled by outer-loop communication; and the leadership and learning of event manager skills. The role was recognized by all team members and evolved organically as resuscitation complexity increased. A "good" manager has similar qualities to a "good team leader" with strong nontechnical skills. Event managers were not formally identified and no specific training had occurred. CONCLUSIONS "Outer-loop" communication supports resuscitation activities. An event manager gives direction to the team, coordinates activities, and supports the team leader. We describe a new role in resuscitation in light of structural organizational theory and cognitive load with a view to incorporating this structure into resuscitation training.
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Affiliation(s)
- Katherine L Taylor
- Department of Anesthesia, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.
| | - Christopher S Parshuram
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Susan Ferri
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Briseida Mema
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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23
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Sutton RM, French B, Meaney PA, Topjian AA, Parshuram CS, Edelson DP, Schexnayder S, Abella BS, Merchant RM, Bembea M, Berg RA, Nadkarni VM. Physiologic monitoring of CPR quality during adult cardiac arrest: A propensity-matched cohort study. Resuscitation 2016; 106:76-82. [PMID: 27350369 DOI: 10.1016/j.resuscitation.2016.06.018] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 06/04/2016] [Accepted: 06/20/2016] [Indexed: 10/21/2022]
Abstract
AIM The American Heart Association (AHA) recommends monitoring cardiopulmonary resuscitation (CPR) quality using end tidal carbon dioxide (ETCO2) or invasive hemodynamic data. The objective of this study was to evaluate the association between clinician-reported physiologic monitoring of CPR quality and patient outcomes. METHODS Prospective observational study of index adult in-hospital CPR events using the AHA's Get With The Guidelines - Resuscitation Registry. Physiologic monitoring was defined using specific database questions regarding use of either ETCO2 or arterial diastolic blood pressure (DBP) to monitor CPR quality. Logistic regression was used to evaluate the association between physiologic monitoring and outcomes in a propensity score matched cohort. RESULTS In the matched cohort, (monitored n=3032; not monitored n=6064), physiologic monitoring of CPR quality was associated with a higher rate of return of spontaneous circulation (ROSC; OR 1.22, CI95 1.04-1.43, p=0.017) compared to no monitoring. Survival to hospital discharge (OR 1.04, CI95 0.91-1.18, p=0.57) and survival with favorable neurological outcome (OR 0.97, CI95 0.75-1.26, p=0.83) were not different between groups. Of index events with only ETCO2 monitoring indicated (n=803), an ETCO2 >10mmHg during CPR was reported in 520 (65%), and associated with improved survival to hospital discharge (OR 2.41, CI95 1.35-4.30, p=0.003), and survival with favorable neurological outcome (OR 2.31, CI95 1.31-4.09, p=0.004) compared to ETCO2 ≤10mmHg. CONCLUSION Clinician-reported use of either ETCO2 or DBP to monitor CPR quality was associated with improved ROSC. An ETCO2 >10mmHg during CPR was associated with a higher rate of survival compared to events with ETCO2 ≤10mmHg.
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Affiliation(s)
- Robert M Sutton
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States.
| | - Benjamin French
- University of Pennsylvania School of Medicine, Department of Biostatistics and Epidemiology, 423 Guardian Drive, Philadelphia, PA 19104, United States
| | - Peter A Meaney
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Alexis A Topjian
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Christopher S Parshuram
- Hospital for Sick Children, Department of Pediatrics 555 University Avenue, Toronto, Ontario, Canada
| | - Dana P Edelson
- University of Chicago, Department of Emergency Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, United States
| | - Stephen Schexnayder
- University of Arkansas College of Medicine/Arkansas Children's Hospital, Department of Pediatrics, One Children's Way, S-4415, Little Rock, AR 72202, United States
| | - Benjamin S Abella
- The Hospital of the University of Pennsylvania, Department of Emergency Medicine, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Raina M Merchant
- The Hospital of the University of Pennsylvania, Department of Emergency Medicine, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Melania Bembea
- Johns Hopkins Hospital/The Charlotte R. Bloomberg Children's Center, 1800 Orleans Street, Suite 6318B Baltimore, MD 21287, United States
| | - Robert A Berg
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Vinay M Nadkarni
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, United States
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Raymond TT, Bonafide CP, Praestgaard A, Nadkarni VM, Berg RA, Parshuram CS, Hunt EA. Pediatric Medical Emergency Team Events and Outcomes: A Report of 3647 Events From the American Heart Association's Get With the Guidelines-Resuscitation Registry. Hosp Pediatr 2016; 6:57-64. [PMID: 26813980 DOI: 10.1542/hpeds.2015-0132] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To describe the clinical characteristics and outcomes of a large, multicenter cohort of pediatric medical emergency team (MET) events occurring in US hospitals reported to the American Heart Association's Get With the Guidelines-Resuscitation registry. METHODS We analyzed consecutive pediatric (<18 years) MET events reported to the registry from January 2006 to February 2012. RESULTS We identified 3647 MET events from 151 US hospitals: 3080 (84%) ward and 567 (16%) telemetry/step-down unit events; median age 3.0 years (interquartile range: 0.0-11.0); 54% male; median duration 29 minutes (interquartile range: 18-49). Triggers included decreased oxygen saturation (32%), difficulty breathing (26%), and staff concern (24%). Thirty-seven percent (1137/3059) were admitted within 24 hours before MET event. Within 24 hours before the MET event, 16% were transferred from a PICU, 24% from an emergency department, and 7% from a pediatric anesthesia care unit. Fifty-three percent of MET events resulted in transfer to a PICU; 3251 (89%) received nonpharmacologic interventions, 2135 (59%) received pharmacologic interventions, 223 (6.1%) progressed to an acute respiratory compromise event, and 17 events (0.5%) escalated to cardiopulmonary arrest during the event. Survival to hospital discharge was 93.3% (n=3299/3536). CONCLUSIONS Few pediatric MET events progress to respiratory or cardiac arrest, but most require nonpharmacologic and pharmacologic intervention. Median duration of MET event was 29 minutes (interquartile range: 18-49), and 53% required transfer to a PICU. Events often occurred within 24 hours after hospital admission or transfer from the PICU, emergency department, or pediatric anesthesia care unit and may represent an opportunity to improve triage and other systems of care.
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Affiliation(s)
- Tia T Raymond
- Department of Pediatrics and Critical Care Medicine, Section of Pediatric Cardiac Intensive Care, Medical City Children's Hospital, Dallas, Texas;
| | | | - Amy Praestgaard
- Department of Biostatistics, The University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Robert A Berg
- Departments of Pediatrics, Critical Care Medicine, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Christopher S Parshuram
- Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, Canada; Department of Paediatrics and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; and
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Mouzaki M, Schwartz SM, Mtaweh H, La Rotta G, Mah K, Herridge J, Van Arsdell G, Parshuram CS, Floh AA. Can Vco 2-Based Estimates of Resting Energy Expenditure Replace the Need for Indirect Calorimetry in Critically Ill Children? JPEN J Parenter Enteral Nutr 2016; 41:619-624. [PMID: 26950946 DOI: 10.1177/0148607115627143] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 11/15/2022]
Abstract
BACKGROUND Optimal energy provision, guided by measured resting energy expenditure (REE), is fundamental in the care of critically ill children. REE should be determined by indirect calorimetry (IC), which has limited availability. Recently, a novel equation was developed for estimating REE derived from carbon dioxide production (Vco2). The aim of this study was to validate the accuracy of this equation in a population of critically ill children following cardiopulmonary bypass (CPB). METHODS This is an ancillary study to a larger trial of children undergoing CPB. Respiratory mass spectrometry was used measure oxygen consumption (Vo2) and Vco2. REE was then calculated according to the established Weir equation (REEW) and the modified, Vco2-based equation (REECO2). The agreement between the 2 measurements was assessed using Bland-Altman plots and mixed-model regressions accounting for repeated measures. RESULTS Data from 104 patients, which included 575 paired measurements, were included. The agreement between REEW and REECO2 was biased during the 72-hour observation period post CPB, with a mean percentage error between measurements of 11% (±7%). The most important determinant of the bias with the Vco2-based equation was the respiratory quotient (RQ). The percentage error between REEW and REECO2 dropped to 4.4% (±2.4%) in those with an RQ between 0.8 and 1. The within-subject variability for RQ in this cohort was wide (11%). CONCLUSIONS IC remains the most accurate method to determine the REE of critically ill patients. Widespread availability of Vco2 data renders Vco2-based approaches to measurement of REE attractive; however, further research is needed to ensure that REE is estimated accurately.
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Affiliation(s)
- Marialena Mouzaki
- 1 Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Steven M Schwartz
- 2 Labatt Family Heart Centre, Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,3 Labatt Family Heart Centre, Division of Cardiology, Physiology and Experimental Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Haifa Mtaweh
- 2 Labatt Family Heart Centre, Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Gustavo La Rotta
- 3 Labatt Family Heart Centre, Division of Cardiology, Physiology and Experimental Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kandice Mah
- 4 Labatt Family Heart Centre, Department of Pediatrics, Division of Cardiology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Joann Herridge
- 5 Department of Dietetics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Glen Van Arsdell
- 6 Labatt Family Heart Centre, Division of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christopher S Parshuram
- 7 Department of Critical Care Medicine, Senior Scientist Child Health Evaluative Sciences, The Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Alejandro A Floh
- 2 Labatt Family Heart Centre, Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Parshuram CS, Amaral ACKB, Ferguson ND, Baker GR, Etchells EE, Flintoft V, Granton J, Lingard L, Kirpalani H, Mehta S, Moldofsky H, Scales DC, Stewart TE, Willan AR, Friedrich JO. Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial. CMAJ 2015; 187:321-9. [PMID: 25667258 DOI: 10.1503/cmaj.140752] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care. METHODS Residents in 2 university-affiliated ICUs were randomly assigned (in 2-month rotation-blocks from January to June 2009) to in-house overnight schedules of 24, 16 or 12 hours. The primary patient outcome was adverse events. The primary resident outcome was sleepiness, measured by the 7-point Stanford Sleepiness Scale. Secondary outcomes were patient deaths, preventable adverse events, and residents' physical symptoms and burnout. Continuity of care and perceptions of ICU staff were also assessed. RESULTS We evaluated 47 (96%) of 49 residents, all 971 admissions, 5894 patient-days and 452 staff surveys. We found no effect of schedule (24-, 16- or 12-h shifts) on adverse events (81.3, 76.3 and 78.2 events per 1000 patient-days, respectively; p = 0.7) or on residents' sleepiness in the daytime (mean rating 2.33, 2.61 and 2.30, respectively; p = 0.3) or at night (mean rating 3.06, 2.73 and 2.42, respectively; p = 0.2). Seven of 8 preventable adverse events occurred with the 12-hour schedule (p = 0.1). Mortality rates were similar for the 3 schedules. Residents' somatic symptoms were more severe and more frequent with the 24-hour schedule (p = 0.04); however, burnout was similar across the groups. ICU staff rated residents' knowledge and decision-making worst with the 16-hour schedule. INTERPRETATION Our findings do not support the purported advantages of shorter duty schedules. They also highlight the trade-offs between residents' symptoms and multiple secondary measures of patient safety. Further delineation of this emerging signal is required before widespread system change. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT00679809.
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Affiliation(s)
- Christopher S Parshuram
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont.
| | - Andre C K B Amaral
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Niall D Ferguson
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - G Ross Baker
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Edward E Etchells
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Virginia Flintoft
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - John Granton
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Lorelei Lingard
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Haresh Kirpalani
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Sangeeta Mehta
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Harvey Moldofsky
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Damon C Scales
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Thomas E Stewart
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Andrew R Willan
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Jan O Friedrich
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
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Abstract
Patient safety is a powerful motivating force for change in modern medicine, and is often cited as a rationale for reducing resident duty hours. However, current data suggest that resident duty hours are not significantly linked to important patient outcomes. We performed a narrative review and identified four potential explanations for these findings. First, we question the relevance of resident fatigue in the creation of harmful errors. Second, we discuss factors, including workload, experience, and individual characteristics, that may be more important determinants of resident fatigue than are duty hours. Third, we describe potential adverse effects that may arise from--and, therefore, counterbalance any potential benefits of--duty hour reductions. Fourth, we explore factors that may mitigate any risks to patient safety associated with using the services of resident trainees. In summary, it may be inappropriate to justify a reduction in working hours on the grounds of a presumed linkage between patient safety and resident duty hours. Better understanding of resident-related factors associated with patient safety will be essential if improvements in important patient safety outcomes are to be realized through resident-focused strategies.
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Affiliation(s)
- Roisin Osborne
- Center for Safety Research, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health and Evaluation Sciences Program, The Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Centre for Patient Safety, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Christopher S Parshuram
- Center for Safety Research, Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health and Evaluation Sciences Program, The Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Centre for Patient Safety, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Affiliation(s)
- Kevin R Imrie
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- The University of Toronto, Toronto, Ontario, Canada
| | - Jason R Frank
- The Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, Canada
- The Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher S Parshuram
- The University of Toronto, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
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Garcia Guerra G, Joffe AR, Senthilselvan A, Kutsogiannis DJ, Parshuram CS. Incidence of milrinone blood levels outside the therapeutic range and their relevance in children after cardiac surgery for congenital heart disease. Intensive Care Med 2013; 39:951-7. [PMID: 23435950 DOI: 10.1007/s00134-013-2858-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 01/21/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate whether variability in milrinone blood levels (MBL) occurs during administration to critically ill children after surgical repair of congenital heart disease, and the clinical relevance of this variability. METHODS Prospective cohort study conducted in the pediatric intensive care unit of a tertiary care teaching and referral hospital. MBL were measured at three time periods after starting milrinone infusion (9-12, 18-24, 40-48 h) and at the end of the infusion. MBL were categorized as within (100-300 ng/ml) or outside the therapeutic range. Low cardiac output syndrome was defined by elevation of either lactate (>2 mmol/l) or arteriovenous oxygen difference (>30%). Five other clinical outcomes were evaluated. Regression analyses evaluated the relationships between MBL and outcomes. RESULTS Sixty-three patients were included with a total of 220 MBL. Quantification of MBL was by high-performance liquid chromatography. Overall, 114 (52%) MBL were outside the therapeutic range: 78 (36%) subtherapeutic, and 36 (16%) supratherapeutic. Repeated-measures analysis found a significant association between supratherapeutic MBL and low cardiac output syndrome (p = 0.02), and supratherapeutic MBL were associated with arterial-central venous oxygen saturation difference >30% at time 3 (p = 0.007). CONCLUSIONS In this cohort, nontherapeutic MBL were common. Further investigation of milrinone dosing recommendations may improve the postoperative outcomes of children.
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Affiliation(s)
- Gonzalo Garcia Guerra
- Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, AB, Canada.
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Ebrahim S, Singh S, S. Parshuram C. Parental satisfaction, involvement, and presence after pediatric intensive care unit admission. J Crit Care 2013; 28:40-5. [DOI: 10.1016/j.jcrc.2012.05.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 04/19/2012] [Accepted: 05/23/2012] [Indexed: 11/27/2022]
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Parshuram CS, Bayliss A, Reimer J, Middaugh K, Blanchard N. Implementing the Bedside Paediatric Early Warning System in a community hospital: A prospective observational study. Paediatr Child Health 2012; 16:e18-22. [PMID: 22379384 DOI: 10.1093/pch/16.3.e18] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2010] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Late transfer of children with critical illness from community hospitals undermines the advantages of community-based care. It was hypothesized that implementation of the Bedside Paediatric Early Warning System (Bedside PEWS) would reduce late transfers. METHODS A prospective before-and-after study was performed in a community hospital 22-bed inpatient paediatric ward. The primary outcome, significant clinical deterioration, was a composite measure of circulatory and respiratory support before transfer. Secondary outcomes were stat calls and resuscitation team calls, paediatrician workload and perceptions of frontline staff. RESULTS Care was evaluated for 842 patient-days before and 2350 patient-days after implementation. The median inpatient census was 13. Implementation of the Bedside PEWS was associated with fewer stat calls to paediatricians (22.6 versus 5.1 per 1000 patient-days; P<0.0001), fewer significant clinical deterioration events (2.4 versus 0.43 per 1000 patient-days; P=0.013), reduced apprehension when calling the physician and no change in paediatrician workload. DISCUSSION Implementation of the Bedside PEWS is feasible and safe, and may improve clinical outcomes.
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Abstract
BACKGROUND Optimal dose adjustment of milrinone in critically ill children is challenging because of conflicting information about the association between dose and outcomes in this age group. OBJECTIVES To describe the use of milrinone in critically ill children and to explore associations between milrinone dosing and clinical outcomes, specifically effectiveness and adverse events. METHODS This retrospective cohort study was performed in a consecutive sample of children admitted to a university-affiliated critical care unit (January to June 2004). The relations between milrinone dosing and its effectiveness (based on prevention of low cardiac output syndrome, defined as a difference in oxygen saturation between arterial and mixed venous blood of at least 30% or an increase in serum lactate > 2 mmol/L) and its adverse effects (thrombocytopenia, arrhythmia) were evaluated by logistic regression. RESULTS A total of 197 children from 213 admissions (ranging in age from newborn to 18 years) were included in the study. Milrinone was initiated with a median loading dose of 99.2 μg/kg (range 22.1-162.2 μg/kg). The initial loading dose was higher if given in the operating room rather than the Critical Care Unit (median 99.7 versus 51.0 μg/kg; p < 0.001). Subsequent loading doses, for patients who received them, were lower (median 49 μg/kg). Milrinone was infused at a median rate of 0.64 μg/kg per minute (range 0.13-2.08 μg/kg per minute) for a median of 43.1 h. There was no relation between serum creatinine level and the maintenance dose of milrinone (r2 ≤ 0.0335). Low cardiac output syndrome was relatively frequent (166 [77.9%] of the 213 admissions). There was a trend for occurrence of this syndrome in patients with greater average milrinone dose rate (odds ratio [OR] 8.21, 95% confidence interval [CI] 0.98-69.15, p = 0.053) and with longer duration of milrinone therapy (OR 1.01, 95% CI 1.01-1.02, p < 0.05). Adverse events were relatively frequent (thrombocytopenia for 27 admissions [12.7%], arrhythmia for 82 admissions [38.5%]) but were not significantly associated with milrinone dosing. CONCLUSIONS A retrospective evaluation of milrinone use in critically ill children revealed variable utilization and frequent occurrence of both low cardiac output syndrome and adverse events. Further prospective research is needed to understand the impact of individual pharmacokinetic differences on pharmacodynamic responses, to guide optimal dose adjustment, improve outcomes, and minimize toxic effects.
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Affiliation(s)
- Teresa Bishara
- Staff Pharmacist with the Department of Pharmacy, North York General Hospital, Toronto, Ontario
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Taylor K, Mayell A, Vandenberg S, Blanchard N, Parshuram CS. Prevalence and indications for video recording in the health care setting in North American and British paediatric hospitals. Paediatr Child Health 2012; 16:e57-60. [PMID: 22851903 DOI: 10.1093/pch/16.7.e57] [Citation(s) in RCA: 17] [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] [Subscribe] [Scholar Register] [Accepted: 04/13/2011] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Health care video recording has demonstrated value in education, performance assessment, quality improvement and clinical care. METHODS A survey was administered to paediatric hospitals in Great Britain, Canada and the United States. Heads of departments or delegates from six areas (emergency departments [EDs], operating rooms, paediatric intensive care units [PICUs], neonatal intensive care units [NICUs], simulation centres and neuroepilepsy units) were asked 10 questions about the prevalence, indications and process issues of video recording. RESULTS Seventy hospitals were surveyed, totalling 307 clinical areas. The hospital response rate was 100%; the rate for clinical departments was 65%. Sixty-six hospitals (94%) currently use video recording. Video recording was used in 62 of 68 (91%) operating rooms; 36 of 69 (52%) PICUs; 35 of 67 (52%) NICUs; 12 of 65 (19%) EDs; seven of eight (88%) neuroepilepsy units and 13 of 14 (93%) simulation centres. Education was the most common indication (112 of 204 [55%]). Most sites obtained written consent. Since the introduction of more strict privacy legislation, 11 of 65 (17%) EDs have discontinued video recording. CONCLUSION The present study describes video recording practices in paediatric hospitals in North America and Great Britain. Video recording is primarily used for education and most areas have a consent process.
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Parshuram CS, Duncan HP, Joffe AR, Farrell CA, Lacroix JR, Middaugh KL, Hutchison JS, Wensley D, Blanchard N, Beyene J, Parkin PC. Multicentre validation of the bedside paediatric early warning system score: a severity of illness score to detect evolving critical illness in hospitalised children. Crit Care 2011; 15:R184. [PMID: 21812993 PMCID: PMC3387627 DOI: 10.1186/cc10337] [Citation(s) in RCA: 147] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Revised: 04/28/2011] [Accepted: 06/30/2011] [Indexed: 11/10/2022]
Abstract
Introduction The timely provision of critical care to hospitalised patients at risk for cardiopulmonary arrest is contingent upon identification and referral by frontline providers. Current approaches require improvement. In a single-centre study, we developed the Bedside Paediatric Early Warning System (Bedside PEWS) score to identify patients at risk. The objective of this study was to validate the Bedside PEWS score in a large patient population at multiple hospitals. Methods We performed an international, multicentre, case-control study of children admitted to hospital inpatient units with no limitations on care. Case patients had experienced a clinical deterioration event involving either an immediate call to a resuscitation team or urgent admission to a paediatric intensive care unit. Control patients had no events. The scores ranged from 0 to 26 and were assessed in the 24 hours prior to the clinical deterioration event. Score performance was assessed using the area under the receiver operating characteristic (AUCROC) curve by comparison with the retrospective rating of nurses and the temporal progression of scores in case patients. Results A total of 2,074 patients were evaluated at 4 participating hospitals. The median (interquartile range) maximum Bedside PEWS scores for the 12 hours ending 1 hour before the clinical deterioration event were 8 (5 to 12) in case patients and 2 (1 to 4) in control patients (P < 0.0001). The AUCROC curve (95% confidence interval) was 0.87 (0.85 to 0.89). In case patients, mean scores were 5.3 at 20 to 24 hours and 8.4 at 0 to 4 hours before the event (P < 0.0001). The AUCROC curve (95% CI) of the retrospective nurse ratings was 0.83 (0.81 to 0.86). This was significantly lower than that of the Bedside PEWS score (P < 0.0001). Conclusions The Bedside PEWS score identified children at risk for cardiopulmonary arrest. Scores were elevated and continued to increase in the 24 hours before the clinical deterioration event. Prospective clinical evaluation is needed to determine whether this score will improve the quality of care and patient outcomes.
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Affiliation(s)
- Christopher S Parshuram
- Department of Critical Care Medicine, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
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Abstract
AIM Digital recording is ubiquitous in the community. Its objectivity, permanence and utility in medical education have led to increasing use in health-care settings. As participants in this process, the perspectives of families are important to inform practice. We surveyed family members of hospitalized children to evaluate their opinions. METHODS A survey was administered to adults in emergency, operating room or ICU waiting areas at a university-affiliated paediatric hospital in Toronto. Respondents rated the frequency of digital recording in the community and hospital environments, the acceptability of five clinical indications and of consent discussions. RESULTS Participants completed 154 surveys (response rate 83%) with median (interquartile range) of 2 (1-2) children. Community use of recording >4 times in the week prior was reported by 47 (31%); 42 (28%) reported no recording. The respondents rated the following indications for digital recording acceptable in the health care research 142 (94%), medical education 140 (93%), quality improvement 140 (92%), patient safety 147 (97%), and clinical care (96%). Within healthcare, consent discussions at different times were rated as acceptable before recording by 99%; after recording by 41%; and with no consent by 17%. CONCLUSION We performed the first post-privacy legislation survey of digital recording in Canadian health care. There is widespread acceptance of digital recording in public spaces and health care; however, respondents preferred to provide consent before recording. Balancing these preferences with the demonstrated advantages of video recording in health care presents challenges for optimal health policy creation. This study provides contemporary data to inform discussions.
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Affiliation(s)
- Katherine Taylor
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.
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Bismilla Z, Breakey VR, Swales J, Kulik DM, Pai N, Singh N, Parshuram CS. Prospective evaluation of residents on call: before and after duty-hour reduction. Pediatrics 2011; 127:1080-7. [PMID: 21606150 DOI: 10.1542/peds.2010-1955] [Citation(s) in RCA: 17] [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] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND On July 1, 2009, in Ontario the maximum period of continuous duty that residents were permitted to work was reduced from 28 to 24 hours. We evaluated the effect of regulation on residents in 3 eras: 2 before (2005 and early 2009) and 1 after (late 2009) the duty-hour reduction. METHODS On-call pediatric residents on pediatric medicine rotations prospectively recorded the numbers of patients (assigned and admitted) and the durations of direct patient care, documentation, staff supervision, and education attended. Sleep was measured with actigraphy. RESULTS The 51 residents worked 180 duty periods, were assigned a median of 6 (interquartile range: 4 -12) daytime patients and 24 (interquartile range: 19-30) overnight patients. Residents reported spending means of 239 minutes providing direct patient care, 235 minutes documenting, and 243 minutes sleeping and receiving 73 minutes of staff supervision and 52 minutes of education. From early 2009 to after duty-hour reduction, residents provided 47 fewer (19.6%) minutes of direct patient care (P = .056) and received 44 fewer minutes (60.3%) of supervision (P = .0005) but spent similar times documenting, receiving education, and sleeping. In early 2009, residents provided 73 more minutes (30.5%) of direct patient care (P = .0016), spent 63 more minutes (26.8%) documenting, and slept 105 fewer minutes (43.0%) (P = .0062) than in 2005. DISCUSSION After duty-hour reduction in 2009, we found reduced supervision and direct patient care. Comparison of the 2 periods before duty-hour reduction showed less sleep and longer patient contact in early 2009, which suggests that changes occurred without regulation.
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Affiliation(s)
- Zia Bismilla
- Department of Paediatrics, Research Institute, Toronto, Ontario, Canada
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Uppal N, Yasseen B, Seto W, Parshuram CS. Drug formulations that require less than 0.1 mL of stock solution to prepare doses for infants and children. CMAJ 2011; 183:E246-8. [PMID: 21262950 DOI: 10.1503/cmaj.100467] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Intravenous doses of medications require formulations that permit accurate preparation and administration. Current equipment does not permit accurate measurement of volumes less than 0.1 mL. In a study of four hypothetical standard pediatric patients, we found that 28 common medications required less than 0.1 mL of available formulation to prepare the dose. In a clinical study of actual use in a pediatric intensive care unit (ICU), 5245 (7.4%) of 71 218 intravenous doses required preparation from less than 0.1 mL of stock solution. For 28.5% of the 1531 ICU admissions, at least one dose was prepared from a volume of less than 0.1 mL. Our findings identify a substantial source of dosing error. Correction will require revision of preparation methods, regulatory requirements and manufacturing practices.
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Kulik DM, Pai N, Bismilla Z, Breakey VR, Parshuram CS. Prospective Observational Study of Clinical Activities, Education and Sleep During Paediatric Resident On-Call Shifts. Paediatr Child Health 2010. [DOI: 10.1093/pch/15.suppl_a.35a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
BACKGROUND AND OBJECTIVES Pharmacotherapy is an under-evaluated element of critical care medicine. In order to better understand pharmacotherapy in pediatric critical illness, we evaluated a cohort of emergency admissions to a university-affiliated pediatric intensive care unit (PICU). METHODS A prospective, observational study was performed. Eligible patients were admitted to this medical-surgical ICU for at least 24 hours. The primary outcomes were the number of drug orders written, the number of different medications ordered, and the number of drug administrations. Multiple regression analyses were used to identify factors independently associated with each primary outcome. RESULTS We studied 100 patients with a median age of 40 months (interquartile range [IQR] 9-82), who were admitted for a total of 851 ICU days. These patients received 4419 drug orders and 11 911 intermittent dose-administrations of 241 different medications. Each patient received a median of 29.5 (IQR 16.5-48.5) drug orders, 14 (IQR 9-18.5) different medications, and 58 (IQR 28-129) drug administrations while in the ICU. The most frequent orders were for morphine 457 (10.6%), furosemide (frusemide) 337 (7.8%), potassium 237 (5.5%), lorazepam 226 (5.2%), and albuterol (salbutamol) 158 (3.7%). The duration of PICU stay and severity of illness were independently associated with all primary outcomes. CONCLUSIONS Pharmacotherapy is an active component in the practice of pediatric critical care medicine. We demonstrated that increasing numbers of ordered medications, drug orders, and drug administrations were associated with increasing duration of ICU therapies and the length of ICU stay. These data underscore the potential importance of improved safety and efficacy of medicines used to treat critically ill children.
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Affiliation(s)
- Conor McDonnell
- Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Ontario, Canada
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Parshuram CS, Hutchison J, Middaugh K. Development and initial validation of the Bedside Paediatric Early Warning System score. Crit Care 2009; 13:R135. [PMID: 19678924 PMCID: PMC2750193 DOI: 10.1186/cc7998] [Citation(s) in RCA: 157] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 06/03/2009] [Accepted: 08/12/2009] [Indexed: 11/13/2022]
Abstract
Introduction Adverse outcomes following clinical deterioration in children admitted to hospital wards is frequently preventable. Identification of children for referral to critical care experts remains problematic. Our objective was to develop and validate a simple bedside score to quantify severity of illness in hospitalized children. Methods A case-control design was used to evaluate 11 candidate items and identify a pragmatic score for routine bedside use. Case-patients were urgently admitted to the intensive care unit (ICU). Control-patients had no 'code blue', ICU admission or care restrictions. Validation was performed using two prospectively collected datasets. Results Data from 60 case and 120 control-patients was obtained. Four out of eleven candidate-items were removed. The seven-item Bedside Paediatric Early Warning System (PEWS) score ranges from 0–26. The mean maximum scores were 10.1 in case-patients and 3.4 in control-patients. The area under the receiver operating characteristics curve was 0.91, compared with 0.84 for the retrospective nurse-rating of patient risk for near or actual cardiopulmonary arrest. At a score of 8 the sensitivity and specificity were 82% and 93%, respectively. The score increased over 24 hours preceding urgent paediatric intensive care unit (PICU) admission (P < 0.0001). In 436 urgent consultations, the Bedside PEWS score was higher in patients admitted to the ICU than patients who were not admitted (P < 0.0001). Conclusions We developed and performed the initial validation of the Bedside PEWS score. This 7-item score can quantify severity of illness in hospitalized children and identify critically ill children with at least one hours notice. Prospective validation in other populations is required before clinical application.
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Affiliation(s)
- Christopher S Parshuram
- Department of Critical Care Medicine, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
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Doherty DR, Parshuram CS, Gaboury I, Hoskote A, Lacroix J, Tucci M, Joffe A, Choong K, Farrell R, Bohn DJ, Hutchison JS. Hypothermia therapy after pediatric cardiac arrest. Circulation 2009; 119:1492-500. [PMID: 19273725 DOI: 10.1161/circulationaha.108.791384] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypothermia therapy improves mortality and functional outcome after cardiac arrest and birth asphyxia in adults and newborns. The effect of hypothermia therapy in infants and children with cardiac arrest is unknown. METHODS AND RESULTS A 2-year, retrospective, 5-center study was conducted, and 222 patients with cardiac arrest were identified. Seventy-nine (35.6%) of these patients met eligibility criteria for the study (age >40 weeks postconception and <18 years, cardiac arrest >3 minutes in duration, survival for > or = 12 hours after return of circulation, and no birth asphyxia). Twenty-nine (36.7%) of these 79 patients received hypothermia therapy and were cooled to 33.7+/-1.3 degrees C for 20.8+/-11.9 hours. Hypothermia therapy was associated with higher mortality (P=0.009), greater duration of cardiac arrest (P=0.005), more resuscitative interventions (P<0.001), higher postresuscitation lactate levels (P<0.001), and use of extracorporeal membrane oxygenation (P<0.001). When adjustment was made for duration of cardiac arrest, use of extracorporeal membrane oxygenation, and propensity scores by use of a logistic regression model, no statistically significant differences in mortality were found (P=0.502) between patients treated with hypothermia therapy and those treated with normothermia. Also, no differences in hypothermia-related adverse events were found between groups. CONCLUSIONS Hypothermia therapy was used in resuscitation scenarios that are associated with greater risk of poor outcome. In an adjusted analysis, the effectiveness of hypothermia therapy was neither supported nor refuted. A randomized controlled trial is needed to rigorously evaluate the benefits and harms of hypothermia therapy after pediatric cardiac arrest.
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Affiliation(s)
- Dermot R Doherty
- Department of Anaesthesia, Division of Pediatric Intensive Care, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
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Uppal NK, Dupuis LL, Parshuram CS. Documentation of pediatric drug safety in manufacturers' product monographs: a cross-sectional evaluation of the canadian compendium of pharmaceuticals and specialities. Paediatr Drugs 2008; 10:193-7. [PMID: 18454571 DOI: 10.2165/00148581-200810030-00007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [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] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To describe the provision of pediatric drug safety information in a national formulary of manufacturers' drug product monographs. METHODS We performed a cross-sectional evaluation of comprehensive product monographs contained in the 2005 Canadian Compendium of Pharmaceuticals and Specialities (CPS). We abstracted data describing indications for prescription, statements about pediatric safety, available preparations, and provision of dosing guidelines. For each monograph we classified pediatric safety data as either present, present but limited or absent. We then described the pediatric safety data in CPS monographs for drugs listed in the published formulary of the Hospital for Sick Children, Toronto, Ontario, Canada. RESULTS A total of 2232 product monographs were screened; 684 were excluded and 1548 (66%) were further analyzed. 1462 (94%) had indications that did not exclude children. Pediatric safety information was present in 592 (38%), present but limited in 148 (10%), and absent in 808 (52%) drug monographs. Safety statements were absent in 224 (14%) drug monographs that provided both dosing guidelines and formulations suitable for administration to children, and in 214 (52%) of 411 drugs in the pediatric hospital formulary. CONCLUSION We evaluated a widely available national source of pediatric prescribing information. Safety data for children was not mentioned in more than half of the product monographs. Moreover, the provision of safety data was discordant with indications for prescription, the availability of pediatric formulations, and dosing guidelines within the monographs, and with inclusion in a pediatric hospital formulary. Our study suggests that the presentation of pediatric safety data in drug product monographs can be improved to better inform prescribing and to optimize pharmacotherapy in children.
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Affiliation(s)
- Navjeet K Uppal
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
Increasing numbers of patients are surviving the intensive care unit. Concordant with our shifting focus to minimizing intensive care unit-acquired morbidity, in the present issue of Critical Care Moyen, Camire, and Stelfox describe the importance of quality pharmacotherapy. They describe challenges and potential solutions to this source of iatrogenic injury in our vulnerable patients. Their article reminds us not to understate the importance of medication error, to avoid overstating the benefits of incompletely proven methods to prevent medication error, and to distinguish harmful medication errors from other types of medication error.
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Parshuram CS, To T, Seto W, Trope A, Koren G, Laupacis A. Systematic evaluation of errors occurring during the preparation of intravenous medication. CMAJ 2008; 178:42-8. [PMID: 18166730 DOI: 10.1503/cmaj.061743] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Errors in the concentration of intravenous medications are not uncommon. We evaluated steps in the infusion-preparation process to identify factors associated with preventable medication errors. METHODS We included 118 health care professionals who would be involved in the preparation of intravenous medication infusions as part of their regular clinical activities. Participants performed 5 infusion-preparation tasks (drug-volume calculation, rounding, volume measurement, dose-volume calculation, mixing) and prepared 4 morphine infusions to specified concentrations. The primary outcome was the occurrence of error (deviation of > 5% for volume measurement and > 10% for other measures). The secondary outcome was the magnitude of error. RESULTS Participants performed 1180 drug-volume calculations, 1180 rounding calculations and made 1767 syringe-volume measurements, and they prepared 464 morphine infusions. We detected errors in 58 (4.9%, 95% confidence interval [CI] 3.7% to 6.2%) drug-volume calculations, 30 (2.5%, 95% CI 1.6% to 3.4%) rounding calculations and 29 (1.6%, 95% CI 1.1% to 2.2%) volume measurements. We found 7 errors (1.6%, 95% CI 0.4% to 2.7%) in drug mixing. Of the 464 infusion preparations, 161 (34.7%, 95% CI 30.4% to 39%) contained concentration errors. Calculator use was associated with fewer errors in dose-volume calculations (4% v. 10%, p = 0.001). Four factors were positively associated with the occurrence of a concentration error: fewer infusions prepared in the previous week (p = 0.007), increased number of years of professional experience (p = 0.01), the use of the more concentrated stock solution (p < 0.001) and the preparation of smaller dose volumes (p < 0.001). Larger magnitude errors were associated with fewer hours of sleep in the previous 24 hours (p = 0.02), the use of more concentrated solutions (p < 0.001) and preparation of smaller infusion doses (p < 0.001). INTERPRETATION Our data suggest that the reduction of provider fatigue and production of pediatric-strength solutions or industry-prepared infusions may reduce medication errors.
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Affiliation(s)
- Christopher S Parshuram
- Department of Critical Care Medicine, and the Center for Safety Research, Child Health Evaluative Sciences Program, the Research Institute, The Hospital for Sick Children, Toronto, Ont.
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Albuali WH, Singh RN, Fraser DD, Seabrook JA, Kavanagh BP, Parshuram CS, Kornecki A. Have changes in ventilation practice improved outcome in children with acute lung injury? Pediatr Crit Care Med 2007; 8:324-30. [PMID: 17545937 DOI: 10.1097/01.pcc.0000269390.48450.af] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [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: 11/26/2022]
Abstract
OBJECTIVES To describe the changes that have occurred in mechanical ventilation in children with acute lung injury in our institution over the last 10-15 yrs and to examine the impact of these changes, in particular of the delivered tidal volume on mortality. DESIGN Retrospective study. SETTING University-affiliated children's hospital. PATIENTS The management of mechanical ventilation between 1988 and 1992 (past group, n = 79) was compared with the management between 2000 and 2004 (recent group, n = 85). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The past group patients were ventilated with a significantly higher mean tidal volume (10.2 +/- 1.7 vs. 8.1 +/- 1.4 mL.kg actual body weight, p < .001), lower levels of positive end-expiratory pressure (6.1 +/- 2.7 vs. 7.1 +/- 2.4 cm H2O, p = .007), and higher mean peak inspiratory pressure (31.5 +/- 7.3 vs. 27.8 +/- 4.2 cm H2O, p < .001) than the recent group patients. The recent group had a lower mortality (21% vs. 35%, p = .04) and a greater number of ventilator-free days (16.0 +/- 9.0 vs. 12.6 +/- 9.9 days, p = .03) than the past group. A higher tidal volume was independently associated with increased mortality (odds ratio 1.59; 95% confidence interval 1.20, 2.10, p < .001) and reduction in ventilation-free days (95% confidence interval -1.24, -0.77, p < .001). CONCLUSIONS The changes in the clinical practice of mechanical ventilation in children in our institution reflect those reported for adults. In our experience, mortality among children with acute lung injury was reduced by 40%, and tidal volume was independently associated with reduced mortality and an increase in ventilation-free days.
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Affiliation(s)
- Waleed H Albuali
- Department of Pediatrics and Pediatric Critical Care Unit, Children's Hospital of Western Ontario, London Health Sciences Center, University of Western Ontario, London, ON, Canada
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VandenBerg SD, Hutchison JS, Parshuram CS. A cross-sectional survey of levels of care and response mechanisms for evolving critical illness in hospitalized children. Pediatrics 2007; 119:e940-6. [PMID: 17387170 DOI: 10.1542/peds.2006-0852] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [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: 11/24/2022] Open
Abstract
OBJECTIVES Recognition and treatment of evolving critical illness is a fundamental element of hospital care. Hospital systems should triage patients to receive appropriate levels of care. We describe here the levels of care, the frequency of near or actual cardiopulmonary arrest (code-blue events), identification mechanisms, and responses to evolving critical illness in hospitalized children. METHODS A cross-sectional telephone survey of Canadian and American hospitals with > or = 50 pediatric acute care beds or > or = 2 pediatric wards was performed. Regression analysis identified factors associated with the frequency of code-blue events after adjustment for hospital volume. RESULTS Responses from 388 (84%) hospitals identified the 181 eligible pediatric hospitals included in this survey. All had a PICU, 99 (55%) had high-dependency units, 101 (56%) had extracorporeal membrane oxygenation therapy, and 69 (38%) used extracorporeal membrane oxygenation therapy for refractory cardiopulmonary arrest. All of the hospitals had immediate-response teams. They were activated 4676 times in the previous 12 months. Twenty-four percent of hospitals had activation criteria for immediate-response teams. Urgent-response teams to treat children who were clinically deteriorating but not at immediate risk of cardiopulmonary arrest were available in 136 (75%) hospitals; 29 (17%) had formal medical emergency teams, and 92 (51%) consulted the PICU. Code-blue events were more common in hospitals with extracorporeal membrane oxygenation therapy, cardiopulmonary bypass, and larger PICU size. CONCLUSIONS Currently, the organization of Canadian and American pediatric hospitals includes dedicated areas to match patient acuity and additional personnel to stabilize and facilitate transfer. The functioning of these systems of care results in calls for immediate medical assistance for ward patients approximately 5000 times annually.
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Affiliation(s)
- Stephanie D VandenBerg
- Department of Critical Care Medicine, Research Institute, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8
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Abstract
Modern medicine is founded on a culture of diligent, fatigued physicians. Fatigue is not desirable; however, the task of managing fatigue in health care professionals is complex and an ideal solution has not been described. Solutions need to integrate the immediate need for continued high-quality patient care, education of trainees, and the limited supply of health and human resources. Exploration of alternate scheduling models, broadened scope of practice, and new models of care delivery in demonstration projects or formal studies should be performed before widespread implementation. Appropriate evaluations are essential if well-meaning but larger scale errors in the name of patient safety are to be avoided.
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Affiliation(s)
- Christopher S Parshuram
- Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
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Duncan H, Hutchison J, Parshuram CS. The Pediatric Early Warning System score: a severity of illness score to predict urgent medical need in hospitalized children. J Crit Care 2006; 21:271-8. [PMID: 16990097 DOI: 10.1016/j.jcrc.2006.06.007] [Citation(s) in RCA: 239] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE We developed and performed the initial retrospective validation of a pediatric severity of illness score. The score is to preemptively identify hospitalized children who are likely to require resuscitation to treat cardiopulmonary arrest. MATERIALS AND METHODS The Pediatric Early Warning System (PEWS) score was developed using expert opinion. The score generated contained 20 items, 16 of which were able to be retrospectively abstracted. Validation used a case-control study design in a Canadian university-affiliated pediatric hospital. Eligible patients were younger than 18 years, were admitted to a hospital ward, and had no level-of-care restrictions. Case patients had a code blue called to obtain immediate assistance for treatment of impending or actual cardiopulmonary arrest. Control patients had no code blue event and were not urgently admitted to the intensive care unit within 48 hours of study. A total of 128 controls and 87 cases were compared. RESULTS The PEWS score area under the receiver operating characteristic curve was 0.90. The sensitivity was 78% and the specificity was 95% at a score of 5. CONCLUSIONS Application of the score may have identified more than 3 quarters of code blue calls in our hospital with at least an hour's warning. After further refinement and validation, the PEWS score has great potential to increase the efficiency of care delivery and to improve the outcomes of care provided to hospitalized children.
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Affiliation(s)
- Heather Duncan
- Paediatric Intensive Care Unit, Diana, Princess of Wales Children's Hospital, Steelhouse Lane, B4 6NH Birmingham, UK
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Parshuram CS, Kirpalani H, Mehta S, Granton J, Cook D. In-house, overnight physician staffing: a cross-sectional survey of Canadian adult and pediatric intensive care units. Crit Care Med 2006; 34:1674-8. [PMID: 16625115 DOI: 10.1097/01.ccm.0000218808.13189.e7] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Physician staffing is an important determinant of patient outcomes following intensive care unit (ICU) admission. We conducted a national survey of in-house after-hours physician staffing in Canadian ICUs. DESIGN : Cross-sectional survey. SETTING Canadian adult and pediatric ICUs. PARTICIPANTS ICU directors. INTERVENTIONS ICU directors of Canadian adult and pediatric ICUs were surveyed to describe overnight staffing by interns, residents, critical care medicine trainees, clinical assistants, and ICU physicians in their ICUs. MEASUREMENTS AND MAIN RESULTS Data were collected regarding hospital and ICU demographics and ICU staffing. For ICUs with in-house overnight physicians, we documented physician experience, shift duration, and clinical responsibilities outside the ICU. We identified 98 Canadian ICU directors, of whom 88 (90%) responded. Dedicated in-house physician coverage overnight was reported in 53 (60%) ICUs, including 13 (15%) in which ICU staff physicians stayed in-house overnight. Compared with ICUs without in-house physicians, those with in-house physicians had more ICU beds (15 vs. 8.5, p=.0001) and fewer ICU staff physicians (5 vs. 7, p=.03). For the 271 physicians who provide overnight staffing, the median level of postgraduate experience was 3 yrs (range, <1 yr, >10 yrs); 129 (48%) had <3 months of ICU experience. Most shifts (83%) were >20 hrs long. CONCLUSIONS In-house overnight physician staffing in Canadian ICUs varies widely. Only a minority of ICUs comply with the 2003 Society of Critical Care Medicine guidelines for adult ICUs recommending continuous in-house staffing by ICU staff physicians. The duration of most ICU shifts raises concern about workload-associated fatigue and medical error. The impact of current nighttime staffing requires further evaluation with respect to patient outcomes.
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Affiliation(s)
- Christopher S Parshuram
- Department of Critical Care Medicine and Division of Clinical Pharmacology, Population Health Sciences, the Research Institute, the Hospital for Sick Children, Toronto, and McMaster University, Hamilton, Ontario, Canada
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de Mos N, van Litsenburg RRL, McCrindle B, Bohn DJ, Parshuram CS. Pediatric in-intensive-care-unit cardiac arrest: incidence, survival, and predictive factors. Crit Care Med 2006; 34:1209-15. [PMID: 16484906 DOI: 10.1097/01.ccm.0000208440.66756.c2] [Citation(s) in RCA: 168] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the incidence, survival, and neurologic outcome of in-intensive-care-unit (ICU) cardiac arrest and to identify factors predictive of survival to hospital discharge. METHODS We performed a retrospective cohort study. Eligible patients were <18 yrs of age and experienced a cardiac arrest during their admission to a multidisciplinary pediatric intensive care unit in the 5.5-yr period ending June 2002. Cardiac arrest was defined as the administration of chest compressions or defibrillation for a nonperfusing cardiac rhythm. Mortality and the Paediatric Cerebral Performance Score were measured and presented according to the Utstein style. Factors predictive of survival to hospital discharge were identified by univariate analysis and independent predictors were identified by multivariate analysis. MAIN MEASUREMENTS AND RESULTS Ninety-one children had cardiac arrest, yielding an incidence of 0.94 cardiac arrests per 100 admissions. Resuscitation was successful in 75 (82%) children, 61 (67%) survived 24 hrs, 25 (27%) children survived to ICU discharge and 23 (25%) to hospital discharge. At hospital discharge, the median Pediatric Cerebral Performance Category score was 2 (range, 1-3) and the median Pediatric Overall Performance Category score was 3 (range, 1-4). No child was assessed as normal on both scores. The independent positive predictors of hospital mortality were the presence of renal failure before cardiac arrest (odds ratio [OR], 6.1; 95% confidence interval [CI], 1.8-31), being on epinephrine infusion at time of cardiac arrest (OR, 9.5; 95% CI, 1.5-62), and the administration of one or more calcium boluses during resuscitation (OR, 5.4; 95% CI, 1.1-25). The use of extracorporeal membrane oxygenation (ECMO) within 24 hrs after cardiac arrest was associated with reduced hospital mortality (OR, 0.18; 95% CI, 0.04-0.76). CONCLUSIONS In-ICU cardiac arrest is associated with high in-hospital mortality and subsequent morbidity in survivors. Prearrest renal dysfunction and epinephrine infusion were associated with increased in-hospital mortality. The use of post-arrest ECMO within 24 hrs was associated with reduced mortality. Rigorous prospective evaluation of the role of ECMO following cardiac arrest is needed.
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Affiliation(s)
- Nienke de Mos
- Department of Critical Care Medicine, Toronto, Ontario, Canada
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