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Ayyala RS, Dillman JR, Tkach JA, Young R, Kotagal M, Depinet H, Trout AT. Implementation of a Program for Appendicitis MRI in a Pediatric Hospital. AJR Am J Roentgenol 2024; 222:e2330695. [PMID: 38230903 DOI: 10.2214/ajr.23.30695] [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] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
MRI is increasingly used as an alternate to CT for the evaluation of suspected appendicitis in pediatric patients presenting to the emergency department (ED) with abdominal pain, when further imaging is needed after an initial ultrasound examination. The available literature shows a similar diagnostic performance of MRI and CT in this setting. At the authors' institution, to evaluate for appendicitis in children in the ED, MRI is performed using a rapid three-sequence free-breathing protocol without IV contrast media. Implementation of an MRI program for appendicitis in children involves multiple steps, including determination of imaging resource availability, collaboration with other services to develop imaging pathways, widespread educational efforts, and regular quality review. Such programs can face numerous practice-specific challenges, such as those involving scanner capacity, costs, and buy-in of impacted groups. Nonetheless, through careful consideration of these factors, MRI can be used to positively impact the care of children presenting to the ED with suspected appendicitis. This Clinical Perspective aims to provide guidance on the development of a program for appendicitis MRI in children, drawing on one institution's experience while highlighting the advantages of MRI and practical strategies for overcoming potential barriers.
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Affiliation(s)
- Rama S Ayyala
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH 45229
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH 45229
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jean A Tkach
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH 45229
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Rachel Young
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH 45229
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Meera Kotagal
- Department of Pediatric Surgery and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH 45229
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Zackoff MW, Cruse B, Sahay RD, Zhang B, Sosa T, Schwartz J, Depinet H, Schumacher D, Geis GL. Multiuser immersive virtual reality simulation for interprofessional sepsis recognition and management. J Hosp Med 2024; 19:185-192. [PMID: 38238875 DOI: 10.1002/jhm.13274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/12/2023] [Accepted: 12/22/2023] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Sepsis is a leading cause of pediatric mortality. While there has been significant effort toward improving adherence to evidence-based care, gaps remain. Immersive multiuser virtual reality (MUVR) simulation may be an approach to enhance provider clinical competency and situation awareness for sepsis. METHODS A prospective, observational pilot of an interprofessional MUVR simulation assessing a decompensating patient from sepsis was conducted from January to June 2021. The study objective was to establish validity and acceptability evidence for the platform by assessing differences in sepsis recognition between experienced and novice participants. Interprofessional teams assessed and managed a patient together in the same VR experience with the primary outcome of time to recognition of sepsis utilizing the Situation Awareness Global Assessment Technique analyzed using a logistic regression model. Secondary outcomes were perceived clinical accuracy, relevancy to practice, and side effects experienced. RESULTS Seventy-two simulations included 144 participants. The cumulative odds ratio of recognizing sepsis at 2 min into the simulation in comparison to later time points by experienced versus novice providers were significantly higher with a cumulative odds ratio of 3.70 (95% confidence interval: 1.15-9.07, p = .004). Participants agreed that the simulation was clinically accurate (98.6%) and will impact their practice (81.1%), with a high degree of immersion (95.7%-99.3%), and the majority of side effects were perceived as mild (70.4%-81.4%). CONCLUSIONS Our novel MUVR simulation demonstrated significant differences in sepsis recognition between experienced and novice participants. This validity evidence along with the data on the simulation's acceptability supports expanded use in training and assessment.
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Affiliation(s)
- Matthew W Zackoff
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Simulation and Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bradley Cruse
- Center for Simulation and Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rashmi D Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bin Zhang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Tina Sosa
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Division of Pediatric Hospital Medicine, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Quality Institute, University of Rochester Medical Center, Rochester, New York
| | - Jerome Schwartz
- Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Holly Depinet
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Daniel Schumacher
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Gary L Geis
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Center for Simulation and Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Clemens N, Wilson PM, Lipshaw MJ, Depinet H, Zhang Y, Eckerle M. Association between positive blood culture and clinical outcomes among children treated for sepsis in the emergency department. Am J Emerg Med 2024; 76:13-17. [PMID: 37972503 DOI: 10.1016/j.ajem.2023.10.045] [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] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 10/02/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE Among children treated for sepsis in a pediatric emergency department (ED), compare clinical features and outcomes between those with blood cultures positive versus negative for a bacterial pathogen. DESIGN Single-center retrospective cohort study. SETTING Pediatric emergency department (ED) at a quaternary pediatric care center. PATIENTS Children aged 0-18 years treated for sepsis defined by the Children's Hospital Association's Improving Pediatric Sepsis Outcomes (IPSO) definition. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed 1307 patients treated for sepsis during the study period, of which 117 (9.0%) had blood cultures positive for a bacterial pathogen. Of children with blood culture positive sepsis, 62 (53.0%) had organ dysfunction compared to 514 (43.2%) with culture negative sepsis (adjusted odds ratio 1.56, 95% confidence interval (CI) 1.04-2.34, adjusting for age, high risk medical conditions, and time to antibiotics). Children with blood culture positive sepsis had a larger base deficit, -4 vs -1 (p < 0.01), and higher procalcitonin, 3.84 vs 0.56 ng/mL (p < 0.01). CONCLUSIONS Children meeting the IPSO Sepsis definition with blood culture positive for a bacterial pathogen have higher rates of organ dysfunction than those who are culture negative, although our 9% rate of blood culture positivity is lower than previously cited literature from the pediatric intensive care unit.
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Affiliation(s)
- Nancy Clemens
- Division of Emergency Medicine, Division of Pediatrics, Geisinger Medical Center, Geisinger Commonwealth School of Medicine, 100 North Academy Ave, Danville, PA 17822, USA.
| | - Paria M Wilson
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnett Ave, Cincinnati, OH 45229, USA
| | - Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnett Ave, Cincinnati, OH 45229, USA
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnett Ave, Cincinnati, OH 45229, USA
| | - Yin Zhang
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnett Ave, Cincinnati, OH 45229, USA
| | - Michelle Eckerle
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, 3333 Burnett Ave, Cincinnati, OH 45229, USA
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Paul R, Niedner M, Riggs R, Richardson T, DeSouza HG, Auletta JJ, Balamuth F, Campbell D, Depinet H, Hueschen L, Huskins WC, Kandil SB, Larsen G, Mack EH, Priebe GP, Rutman LE, Schafer M, Scott H, Silver P, Stalets EL, Wathen BA, Macias CG, Brilli RJ. Bundled Care to Reduce Sepsis Mortality: The Improving Pediatric Sepsis Outcomes (IPSO) Collaborative. Pediatrics 2023; 152:e2022059938. [PMID: 37435672 DOI: 10.1542/peds.2022-059938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 07/13/2023] Open
Abstract
OBJECTIVES We sought to improve utilization of a sepsis care bundle and decrease 3- and 30- day sepsis-attributable mortality, as well as determine which care elements of a sepsis bundle are associated with improved outcomes. METHODS Children's Hospital Association formed a QI collaborative to Improve Pediatric Sepsis Outcomes (IPSO) (January 2017-March 2020 analyzed here). IPSO Suspected Sepsis (ISS) patients were those without organ dysfunction where the provider "intended to treat" sepsis. IPSO Critical Sepsis (ICS) patients approximated those with septic shock. Process (bundle adherence), outcome (mortality), and balancing measures were quantified over time using statistical process control. An original bundle (recognition method, fluid bolus < 20 min, antibiotics < 60 min) was retrospectively compared with varying bundle time-points, including a modified evidence-based care bundle, (recognition method, fluid bolus < 60 min, antibiotics < 180 min). We compared outcomes using Pearson χ-square and Kruskal Wallis tests and adjusted analysis. RESULTS Reported are 24 518 ISS and 12 821 ICS cases from 40 children's hospitals (January 2017-March 2020). Modified bundle compliance demonstrated special cause variation (40.1% to 45.8% in ISS; 52.3% to 57.4% in ICS). The ISS cohort's 30-day, sepsis-attributable mortality dropped from 1.4% to 0.9%, a 35.7% relative reduction over time (P < .001). In the ICS cohort, compliance with the original bundle was not associated with a decrease in 30-day sepsis-attributable mortality, whereas compliance with the modified bundle decreased mortality from 4.75% to 2.4% (P < .01). CONCLUSIONS Timely treatment of pediatric sepsis is associated with reduced mortality. A time-liberalized care bundle was associated with greater mortality reductions.
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Affiliation(s)
- Raina Paul
- Division of Emergency Medicine, Children's Hospital of Orange County, University of California Irvine, Orange California
| | | | - Ruth Riggs
- Children's Hospital Association, Lenexa, Kansas
| | | | | | - Jeffery J Auletta
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Frances Balamuth
- Department of Pediatrics, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Holly Depinet
- Departments of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Leslie Hueschen
- University of Missouri-Kansas City, Children's Mercy Hospital, Kansas City, Missouri
| | - W Charles Huskins
- Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, Minnesota
| | - Sarah B Kandil
- Department of Pediatrics, Yale University School of Medicine, Yale New Haven Children's Hospital, New Haven, Connecticut
| | - Gitte Larsen
- Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Elizabeth H Mack
- Medical University of South Carolina Children's Health, Charleston, South Carolina
| | - Gregory P Priebe
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
| | - Lori E Rutman
- University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Melissa Schafer
- State University of New York Upstate Medical Center, Syracuse, New York
| | - Halden Scott
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Denver, Colorado
| | - Pete Silver
- Cohen Children's Medical Center of New York, Queens, New York
| | - Erika L Stalets
- Departments of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Charles G Macias
- Division of Pediatric Emergency Medicine, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Richard J Brilli
- Nationwide Children's Hospital, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Columbus, Ohio
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Mullan PC, Pruitt CM, Levasseur KA, Macias CG, Paul R, Depinet H, Nguyen ATH, Melendez E. Intravenous Fluid Bolus Rates Associated with Outcomes in Pediatric Sepsis: A Multi-Center Analysis. OAEM 2022; 14:375-384. [PMID: 35924031 PMCID: PMC9342868 DOI: 10.2147/oaem.s368442] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/16/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Patients and Methods Results Conclusion
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Affiliation(s)
- Paul C Mullan
- Department of Pediatrics, Division of Emergency Medicine, Eastern Virginia Medical School, Children’s Hospital of the King’s Daughters, Norfolk, VA, USA
- Correspondence: Paul C Mullan, Email
| | - Christopher M Pruitt
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Kelly A Levasseur
- Pediatric Emergency Medicine, Beaumont Children’s Hospital, Royal Oak, MI, USA
| | - Charles G Macias
- Division of Pediatric Emergency Medicine, University Hospitals Rainbow Babies and Children’s, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Raina Paul
- Department of Emergency Medicine, Advocate Children’s Hospital, Park Ridge, IL, USA
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Anh Thy H Nguyen
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, St. Petersburg, FL, USA
| | - Elliot Melendez
- Division of Pediatric Critical Care, Connecticut Children’s Medical Center, University of Connecticut, Hartford, CT, USA
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Balamuth F, Scott HF, Weiss SL, Webb M, Chamberlain JM, Bajaj L, Depinet H, Grundmeier RW, Campos D, Deakyne Davies SJ, Simon NJ, Cook LJ, Alpern ER. Validation of the Pediatric Sequential Organ Failure Assessment Score and Evaluation of Third International Consensus Definitions for Sepsis and Septic Shock Definitions in the Pediatric Emergency Department. JAMA Pediatr 2022; 176:672-678. [PMID: 35575803 PMCID: PMC9112137 DOI: 10.1001/jamapediatrics.2022.1301] [Citation(s) in RCA: 15] [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: 11/14/2022]
Abstract
IMPORTANCE Pediatric sepsis definitions have evolved, and some have proposed using the measure used in adults to quantify organ dysfunction, a Sequential Organ Failure Assessment (SOFA) score of 2 or more in the setting of suspected infection. A pediatric adaptation of SOFA (pSOFA) showed excellent discrimination for mortality in critically ill children but has not been evaluated in an emergency department (ED) population. OBJECTIVE To delineate test characteristics of the pSOFA score for predicting in-hospital mortality among (1) all patients and (2) patients with suspected infection treated in pediatric EDs. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study took place from January 1, 2012, to January 31, 2020 in 9 US children's hospitals included in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. The data was analyzed from February 1, 2020, to April 18, 2022. All ED visits for patients younger than 18 years were included. EXPOSURES ED pSOFA score was assigned by summing maximum pSOFA organ dysfunction components during ED stay (each 0-4 points). In the subset with suspected infection, visit meeting criteria for sepsis (suspected infection with a pSOFA score of 2 or more) and septic shock (suspected infection with vasoactive infusion and serum lactate level >18.0 mg/dL) were identified. MAIN OUTCOMES AND MEASURES Test characteristics of pSOFA scores of 2 or more during the ED stay for hospital mortality. RESULTS A total of 3 999 528 (female, 47.3%) ED visits were included. pSOFA scores ranged from 0 to 16, with 126 250 visits (3.2%) having a pSOFA score of 2 or more. pSOFA scores of 2 or more had sensitivity of 0.65 (95% CI, 0.62-0.67) and specificity of 0.97 (95% CI, 0.97-0.97), with negative predictive value of 1.0 (95% CI, 1.00-1.00) in predicting hospital mortality. Of 642 868 patients with suspected infection (16.1%), 42 992 (6.7%) met criteria for sepsis, and 374 (0.1%) met criteria for septic shock. Hospital mortality rates for suspected infection (599 502), sepsis (42 992), and septic shock (374) were 0.0%, 0.9%, and 8.0%, respectively. The pSOFA score had similar discrimination for hospital mortality in all ED visits (area under receiver operating characteristic curve, 0.81; 95% CI, 0.79-0.82) and the subset with suspected infection (area under receiver operating characteristic curve, 0.82; 95% CI, 0.80-0.84). CONCLUSIONS AND RELEVANCE In a large, multicenter study of pediatric ED visits, a pSOFA score of 2 or more was uncommon and associated with increased hospital mortality yet had poor sensitivity as a screening tool for hospital mortality. Conversely, children with a pSOFA score of 2 or less were at very low risk of death, with high specificity and negative predictive value. Among patients with suspected infection, patients with pSOFA-defined septic shock demonstrated the highest mortality.
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Affiliation(s)
- Fran Balamuth
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Scott L. Weiss
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | | | - Holly Depinet
- Cincinnnati Children’s Hospital and Medical Center, Cincinnati, Ohio
| | - Robert W. Grundmeier
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Diego Campos
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Depinet H, Macias CG, Balamuth F, Lane RD, Luria J, Melendez E, Myers SR, Patel B, Richardson T, Zaniletti I, Paul R. Pediatric Septic Shock Collaborative Improves Emergency Department Sepsis Care in Children. Pediatrics 2022; 149:184791. [PMID: 35229124 DOI: 10.1542/peds.2020-007369] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 11/24/2022] Open
Abstract
OBJECTIVES The pediatric emergency department (ED)-based Pediatric Septic Shock Collaborative (PSSC) aimed to improve mortality and key care processes among children with presumed septic shock. METHODS This was a multicenter learning and improvement collaborative of 19 pediatric EDs from November 2013 to May 2016 with shared screening and patient identification recommendations, bundles of care, and educational materials. Process metrics included minutes to initial vital sign assessment and to first and third fluid bolus and antibiotic administration. Outcomes included 3- and 30-day all-cause in-hospital mortality, hospital and ICU lengths of stay, hours on increased ventilation (including new and increases from chronic baseline in invasive and noninvasive ventilation), and hours on vasoactive agent support. Analysis used statistical process control charts and included both the overall sample and an ICU subgroup. RESULTS Process improvements were noted in timely vital sign assessment and receipt of antibiotics in the overall group. Timely first bolus and antibiotics improved in the ICU subgroup. There was a decrease in 30-day all-cause in-hospital mortality in the overall sample. CONCLUSIONS A multicenter pediatric ED improvement collaborative showed improvement in key processes for early sepsis management and demonstrated that a bundled quality improvement-focused approach to sepsis management can be effective in improving care.
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Affiliation(s)
- Holly Depinet
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Charles G Macias
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Fran Balamuth
- Division of Emergency Medicine, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Roni D Lane
- Division of Emergency Medicine, Primary Children's Hospital and Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Joseph Luria
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Elliot Melendez
- Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Sage R Myers
- Division of Emergency Medicine, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Binita Patel
- Section of Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | | | | | - Raina Paul
- Department of Emergency Medicine, Advocate Children's Hospital, Park Ridge, Illinois
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Jeffreys KL, Eckerle M, Depinet H. Patterns of Vasoactive Agent Initiation Among Children With Septic Shock in the Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e205-e208. [PMID: 32941359 DOI: 10.1097/pec.0000000000002219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to describe patterns of initiation (and factors associated with delayed initiation) of vasoactive agents among pediatric emergency patients with septic shock. METHODS Patients with septic shock from November 2013 to September 2016 who had a vasoactive agent initiated for documented hypotension were classified as "guideline adherent" (hypotensive following the final fluid bolus and had vasoactive agents initiated within 60 minutes) or "delayed initiation" (hypotensive after the final bolus and were initiated on vasoactive agents after >60 minutes). Patient-level factors (demographics, presence of underlying condition including central venous catheter, and markers of disease severity) and outcomes (mortality, length of stay) were compared between groups. RESULTS Of the 37 eligible patients, 17 received vasoactive agents within "guideline adherent" timelines and 10 were "delayed initiation." An additional group was identified as "transient responders"; these patients were normotensive after a final fluid bolus but developed hypotension and were initiated on a vasoactive agent within 2 hours after admission (n = 10). We found no significant difference between the "guideline adherent" and "delayed initiation" groups according to patient-level factors or outcomes; "transient responders" were more likely than other groups to have a central venous catheter and had longer lengths of stay. CONCLUSIONS Although there are perceived barriers to vasoactive agent initiation, we found no significant difference in patient-level factors between the timely and delayed groups. This study also identified a group of patients labeled as transient responders, who initially appeared volume responsive but who required vasoactive support within several hours. This cohort requires further study.
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Affiliation(s)
- Kristen L Jeffreys
- From the Division of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center; University of Cincinnati School of Medicine
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Paul R, Niedner M, Brilli R, Macias C, Riggs R, Balamuth F, Depinet H, Larsen G, Huskins C, Scott H, Lucasiewicz G, Schaffer M, DeSouza HG, Silver P, Richardson T, Hueschen L, Campbell D, Wathen B, Auletta JJ. Metric Development for the Multicenter Improving Pediatric Sepsis Outcomes (IPSO) Collaborative. Pediatrics 2021; 147:peds.2020-017889. [PMID: 33795482 PMCID: PMC8131032 DOI: 10.1542/peds.2020-017889] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND A 56 US hospital collaborative, Improving Pediatric Sepsis Outcomes, has developed variables, metrics and a data analysis plan to track quality improvement (QI)-based patient outcomes over time. Improving Pediatric Sepsis Outcomes expands on previous pediatric sepsis QI efforts by improving electronic data capture and uniformity across sites. METHODS An expert panel developed metrics and corresponding variables to assess improvements across the care delivery spectrum, including the emergency department, acute care units, hematology and oncology, and the ICU. Outcome, process, and balancing measures were represented. Variables and statistical process control charts were mapped to each metric, elucidating progress over time and informing plan-do-study-act cycles. Electronic health record (EHR) abstraction feasibility was prioritized. Time 0 was defined as time of earliest sepsis recognition (determined electronically), or as a clinically derived time 0 (manually abstracted), identifying earliest physiologic onset of sepsis. RESULTS Twenty-four evidence-based metrics reflected timely and appropriate interventions for a uniformly defined sepsis cohort. Metrics mapped to statistical process control charts with 44 final variables; 40 could be abstracted automatically from multiple EHRs. Variables, including high-risk conditions and bedside huddle time, were challenging to abstract (reported in <80% of encounters). Size or type of hospital, method of data abstraction, and previous QI collaboration participation did not influence hospitals' abilities to contribute data. To date, 90% of data have been submitted, representing 200 007 sepsis episodes. CONCLUSIONS A comprehensive data dictionary was developed for the largest pediatric sepsis QI collaborative, optimizing automation and ensuring sustainable reporting. These approaches can be used in other large-scale sepsis QI projects in which researchers seek to leverage EHR data abstraction.
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Affiliation(s)
- Raina Paul
- Division of Emergency Medicine, Advocate Children's Hospital, Park Ridge, Illinois;
| | - Matthew Niedner
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Richard Brilli
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Charles Macias
- Division of Pediatric Emergency Medicine, Rainbow Babies and Children’s Hospital and Case Western Reserve University, Cleveland, Ohio
| | - Ruth Riggs
- Children’s Hospital Association, Lenexa, Kansas
| | - Frances Balamuth
- Department of Pediatrics, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Gitte Larsen
- Pediatric Critical Care, Department of Pediatrics, Primary Children’s Hospital, Salt Lake City, Utah
| | - Charlie Huskins
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Halden Scott
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado,Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Aurora, Colorado
| | | | - Melissa Schaffer
- Department of Pediatrics, Upstate Medical University, Syracuse, New York
| | | | - Pete Silver
- Department of Pediatrics, Zucker School of Medicine at Hofstra, Cohen Children’s Medical Center, East Garden City, New York
| | | | - Leslie Hueschen
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Missouri-Kansas City and Children’s Mercy Hospital, Kansas City, Missouri
| | | | - Beth Wathen
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado,Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Aurora, Colorado
| | - Jeffery J. Auletta
- Divisions of Hematology, Oncology, and Blood and Marrow Transplant and Infectious Diseases, Department of Pediatrics, Nationwide Children’s Hospital and College of Medicine, The Ohio State University, Columbus, Ohio
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Lloyd J, Depinet H, Zhang Y, Semenova O, Meinzen-Derr J, Babcock L. Comparison of children receiving emergent sepsis care by mode of arrival. Am J Emerg Med 2021; 47:217-222. [PMID: 33906128 DOI: 10.1016/j.ajem.2021.04.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/17/2021] [Accepted: 04/19/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To determine if differences in patient characteristics, treatments, and outcomes exist between children with sepsis who arrive by emergency medical services (EMS) versus their own mode of transport (self-transport). METHODS Retrospective cohort study of patients who presented to the Emergency Department (ED) of two large children's hospitals and treated for sepsis from November 2013 to June 2017. Presentation, ED treatment, and outcomes, primarily time to first bolus and first parental antibiotic, were compared between those transported via EMS versus patients who were self-transported. RESULTS Of the 1813 children treated in the ED for sepsis, 1452 were self-transported and 361 were transported via EMS. The EMS group were more frequently male, of black race, and publicly insured than the self-transport group. The EMS group was more likely to have a critical triage category, receive initial care in the resuscitation suite (51.9 vs. 22%), have hypotension at ED presentation (14.4 vs. 5.4%), lactate >2.0 mmol/L (60.6 vs. 40.8%), vasoactive agents initiated in the ED (8.9 vs. 4.9%), and to be intubated in the ED (14.4 vs. 2.8%). The median time to first IV fluid bolus was faster in the EMS group (36 vs. 57 min). Using Cox LASSO to adjust for potential covariates, time to fluids remained faster for the EMS group (HR 1.26, 95% CI 1.12, 1.42). Time to antibiotics, ICU LOS, 3- or 30-day mortality rates did not differ, yet median hospital LOS was significantly longer in those transported by EMS versus self-transported (6.5 vs. 5.3 days). CONCLUSIONS Children with sepsis transported by EMS are a sicker population of children than those self-transported on arrival and had longer hospital stays. EMS transport was associated with earlier in-hospital fluid resuscitation but no difference in time to first antibiotic. Improved prehospital recognition and care is needed to promote adherence to both prehospital and hospital-based sepsis resuscitation benchmarks.
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Affiliation(s)
- Julia Lloyd
- Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, United States of America.
| | - Holly Depinet
- Department of Pediatrics, University of Cincinnati, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45249, United States of America.
| | - Yin Zhang
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45249, United States of America.
| | - Olga Semenova
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45249, United States of America.
| | - Jareen Meinzen-Derr
- University of Cincinnati, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45249, United States of America.
| | - Lynn Babcock
- Department of Pediatrics, University of Cincinnati, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45249, United States of America.
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Abstract
OBJECTIVE The aim of this study was to identify emergency department (ED) heart rate (HR) values that identify children at elevated risk of ED revisit with admission. METHODS We performed a retrospective cohort study of patients 0 to 18 years old discharged from a tertiary-care pediatric ED from January 2013 to December 2014. We created percentile curves for the last recorded HR for age using data from calendar year 2013 and used receiver operating characteristic (ROC) curves to characterize the performance of the percentiles for predicting ED revisit with admission within 72 hours. In a held-out validation data set (calendar year 2014 data), we evaluated test characteristics of last-recorded HR-for-age cut points identified as promising on the ROC curves, as well as those identifying the highest 5% and 1% of last recorded HRs for age. RESULTS We evaluated 183,433 eligible ED visits. Last recorded HR for age had poor discrimination for predicting revisit with admission (area under the curve, 0.61; 95% confidence interval, 0.58-0.63). No promising cut points were identified on the ROC curves. Cut points identifying the highest 5% and 1% of last recorded HRs for age showed low sensitivity (10.1% and 2.5%) with numbers needed to evaluate of 62 and 50, respectively, to potentially prevent 1 revisit with admission. CONCLUSIONS Last recorded ED HR discriminates poorly between children who are and are not at risk of revisit with admission in a pediatric ED. The use of single-parameter HR in isolation as an automated trigger for mandatory reevaluation prior to discharge may not improve revisit outcomes.
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Affiliation(s)
- Carrie Daymont
- Departments of Pediatrics and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Fran Balamuth
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Halden F Scott
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christopher P Bonafide
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Holly Depinet
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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12
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Larsen GY, Brilli R, Macias CG, Niedner M, Auletta JJ, Balamuth F, Campbell D, Depinet H, Frizzola M, Hueschen L, Lowerre T, Mack E, Paul R, Razzaqi F, Schafer M, Scott HF, Silver P, Wathen B, Lukasiewicz G, Stuart J, Riggs R, Richardson T, Ward L, Huskins WC. Development of a Quality Improvement Learning Collaborative to Improve Pediatric Sepsis Outcomes. Pediatrics 2021; 147:e20201434. [PMID: 33328337 PMCID: PMC7874527 DOI: 10.1542/peds.2020-1434] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [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] [Accepted: 10/20/2020] [Indexed: 12/29/2022] Open
Abstract
Pediatric sepsis is a major public health problem. Published treatment guidelines and several initiatives have increased adherence with guideline recommendations and have improved patient outcomes, but the gains are modest, and persistent gaps remain. The Children's Hospital Association Improving Pediatric Sepsis Outcomes (IPSO) collaborative seeks to improve sepsis outcomes in pediatric emergency departments, ICUs, general care units, and hematology/oncology units. We developed a multicenter quality improvement learning collaborative of US children's hospitals. We reviewed treatment guidelines and literature through 2 in-person meetings and multiple conference calls. We defined and analyzed baseline sepsis-attributable mortality and hospital-onset sepsis and developed a key driver diagram (KDD) on the basis of treatment guidelines, available evidence, and expert opinion. Fifty-six hospital-based teams are participating in IPSO; 100% of teams are engaged in educational and information-sharing activities. A baseline, sepsis-attributable mortality of 3.1% was determined, and the incidence of hospital-onset sepsis was 1.3 cases per 1000 hospital admissions. A KDD was developed with the aim of reducing both the sepsis-attributable mortality and the incidence of hospital-onset sepsis in children by 25% from baseline by December 2020. To accomplish these aims, the KDD primary drivers focus on improving the following: treatment of infection; recognition, diagnosis, and treatment of sepsis; de-escalation of unnecessary care; engagement of patients and families; and methods to optimize performance. IPSO aims to improve sepsis outcomes through collaborative learning and reliable implementation of evidence-based interventions.
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Affiliation(s)
- Gitte Y Larsen
- Pediatric Critical Care, Primary Children's Hospital and Department of Pediatrics, University of Utah, Salt Lake City, Utah;
| | | | - Charles G Macias
- Pediatric Emergency Medicine, Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio
| | - Matthew Niedner
- Pediatric Critical Care, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Jeffery J Auletta
- Hematology, Oncology, and Blood and Marrow Transplant, and Infectious Diseases, Nationwide Children's Hospital, Columbus, Ohio
| | - Fran Balamuth
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Deborah Campbell
- Infection Prevention and Quality, Kentucky Hospital Association, Louisville, Kentucky
| | - Holly Depinet
- Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Meg Frizzola
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Leslie Hueschen
- Pediatric Emergency Medicine, Children's Mercy Hospital and University of Missouri, Kansas City, Missouri
| | - Tracy Lowerre
- Acute Care Pediatric Unit, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Elizabeth Mack
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Raina Paul
- Pediatric Emergency Medicine, Advocate Children's Hospital, Park Ridge, Illinois
| | - Faisal Razzaqi
- Pediatric Hematology and Oncology, Valley Children's Hospital, Madera, California
| | - Melissa Schafer
- Department of Pediatrics, State University of New York Upstate Medical University and Upstate Golisano Children's Hospital, Syracuse, New York
| | - Halden F Scott
- Pediatric Emergency Medicine, Children's Hospital Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Pete Silver
- Cohen Children's Medical Center of New York and Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Queens, New York
| | - Beth Wathen
- Pediatric ICU, Children's Hospital Colorado, Aurora, Colorado
| | - Gloria Lukasiewicz
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Jayne Stuart
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Ruth Riggs
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Troy Richardson
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - Lowrie Ward
- Children's Hospital Association, Lenexa, Kansas
- Children's Hospital Association, Washington, District of Columbia; and
| | - W Charles Huskins
- Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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13
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Hanson HR, Carlisle MA, Bensman RS, Byczkowski T, Depinet H, Terrell TC, Pitner H, Knox R, Goldstein SL, Basu RK. Early prediction of pediatric acute kidney injury from the emergency department: A pilot study. Am J Emerg Med 2020; 40:138-144. [PMID: 32024590 DOI: 10.1016/j.ajem.2020.01.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 10/08/2019] [Revised: 01/15/2020] [Accepted: 01/26/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Identifying acute kidney injury (AKI) early can inform medical decisions key to mitigation of injury. An AKI risk stratification tool, the renal angina index (RAI), has proven better than creatinine changes alone at predicting AKI in critically ill children. OBJECTIVE To derive and test performance of an "acute" RAI (aRAI) in the Emergency Department (ED) for prediction of inpatient AKI and to evaluate the added yield of urinary AKI biomarkers. METHODS Study of pediatric ED patients with sepsis admitted and followed for 72 h. The primary outcome was inpatient AKI defined by a creatinine >1.5× baseline, 24-72 h after admission. Patients were denoted renal angina positive (RA+) for an aRAI score above a population derived cut-off. Test characteristics evaluated predictive performance of the aRAI compared to changes in creatinine and incorporation of 4 urinary biomarkers in the context of renal angina were assessed. RESULTS 118 eligible subjects were enrolled. Mean age was 7.8 ± 6.4 years, 16% required intensive care admission. In the ED, 27% had a +RAI (22% had a >50% creatinine increase). The aRAI had an AUC of 0.92 (0.86-0.98) for prediction of inpatient AKI. For AKI prediction, RA+ demonstrated a sensitivity of 94% (69-99) and a negative predictive value of 99% (92-100) (versus sensitivity 59% (33-82) and NPV 93% (89-96) for creatinine ≥2× baseline). Biomarker analysis revealed a higher AUC for aRAI alone than any individual biomarker. CONCLUSIONS This pilot study finds the aRAI to be a sensitive ED-based tool for ruling out the development of in-hospital AKI.
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Affiliation(s)
- Holly R Hanson
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America.
| | - Michael A Carlisle
- Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America.
| | - Rachel S Bensman
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America; Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America.
| | - Terri Byczkowski
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America.
| | - Holly Depinet
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2008, Cincinnati, OH 45229, United States of America; Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America.
| | - Tara C Terrell
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America
| | - Hilary Pitner
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America
| | - Ryan Knox
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America.
| | - Stuart L Goldstein
- Department of General Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, United States of America; Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America.
| | - Rajit K Basu
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, United States of America.
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Riney LC, Treasure JD, Varnell CD, Depinet H. Case 6: An Infant Presenting with Hematuria and Pallor. Pediatr Rev 2018; 39:98-99. [PMID: 29437133 PMCID: PMC5905330 DOI: 10.1542/pir.2016-0112] [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: 11/24/2022]
Affiliation(s)
| | | | - Charles D Varnell
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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15
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Fullerton K, Depinet H, Iyer S, Hall M, Herr S, Morton I, Lee T, Melzer-Lange M. Association of Hospital Resources and Imaging Choice for Appendicitis in Pediatric Emergency Departments. Acad Emerg Med 2017; 24:400-409. [PMID: 28039951 DOI: 10.1111/acem.13156] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/22/2016] [Accepted: 12/19/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Abdominal pain and concern for appendicitis are common chief complaints in patients presenting to the pediatric emergency department (PED). Although many professional organizations recommend decreasing use of computed tomography (CT) and choosing ultrasound as first-line imaging for pediatric appendicitis, significant variability persists in imaging utilization. This study investigated practice variation across children's hospitals in the diagnostic imaging evaluation of appendicitis and determined hospital-level characteristics associated with the likelihood of ultrasound as the first imaging modality. METHODS This was a multicenter (seven children's hospitals) retrospective investigation. Data from chart review of 160 consecutive patients aged 3-18 years diagnosed with appendicitis from each site were compared with a survey of site medical directors regarding hospital resource availability, usual practices, and departmental-level demographics. RESULTS In the diagnostic evaluation of 1,090 children with appendicitis, CT scan was performed first for 22.4% of patients, with a range across PEDs of 3.1% to 83.8%. Ultrasound was performed for 54.0% of patients with a range of 2.5% to 96.9%. The only hospital-level factor significantly associated with ultrasound as the first imaging modality was 24-hour availability of in-house ultrasound (odds ratio = 29.2, 95% confidence interval = 1.2-691.8). CONCLUSION Across children's hospitals, significant practice variation exists regarding diagnostic imaging in the evaluation of patients with appendicitis. Variation in hospital-level resources may impact the diagnostic evaluation of patients with appendicitis. Availability of 24-hour in-house ultrasound significantly increases the likelihood of ultrasound as first imaging and decreases CT scans. Hospitals aiming to increase the use of ultrasound should consider adding 24-hour in-house coverage.
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Affiliation(s)
| | - Holly Depinet
- Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Sujit Iyer
- Dell Children's Medical Center; Austin TX
| | - Matt Hall
- Children's Hospital Association; Overland Park KS
| | | | - Inge Morton
- Children's Hospital Los Angeles; Los Angeles CA
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16
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Depinet H, Copeland K, Gogain J, Hennes H, Paradis NA, Andrews-Dickert R, Vance CW, Huckins DS. Addition of a biomarker panel to a clinical score to identify patients at low risk for appendicitis. Am J Emerg Med 2016; 34:2266-2271. [DOI: 10.1016/j.ajem.2016.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/31/2016] [Accepted: 08/08/2016] [Indexed: 12/29/2022] Open
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17
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Depinet H, von Allmen D, Towbin A, Hornung R, Ho M, Alessandrini E. Risk Stratification to Decrease Unnecessary Diagnostic Imaging for Acute Appendicitis. Pediatrics 2016; 138:peds.2015-4031. [PMID: 27553220 DOI: 10.1542/peds.2015-4031] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There has been an increase in the use of imaging modalities to diagnose appendicitis despite evidence that can help identify children at especially high or low risk of appendicitis who may not benefit. We hypothesized that the passive diffusion of a standardized care pathway (including diagnostic imaging recommendations) would improve the diagnostic workup of appendicitis by safely decreasing the use of unnecessary imaging when compared with historical controls and that an electronic, real-time decision support tool would decrease unnecessary imaging. METHODS We used an interrupted time series trial to compare proportions of patients who underwent diagnostic imaging (computed tomography [CT] and ultrasound) between 3 time periods: baseline historical controls, after passive diffusion of a diagnostic workup clinical pathway, and after introduction of an electronic medical record-embedded clinical decision support tool that provides point-of-care imaging recommendations (active intervention). RESULTS The moderate- and high-risk groups showed lower proportions of CT in the passive and active intervention time periods compared with the historical control group. Proportions of patients undergoing ultrasound in all 3 risk groups showed an increase from the historical baseline. Time series analysis confirmed that time trends within any individual time period were not significant; thus, incidental secular trends over time did not appear to explain the decreased use of CT. CONCLUSIONS Passive and active decision support tools minimized unnecessary CT imaging; long-term effects remain an important area of study.
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Affiliation(s)
- Holly Depinet
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Alex Towbin
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Richard Hornung
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mona Ho
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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