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Hillyer MM, Jaggi P, Chanani NK, Fernandez AJ, Zaki H, Fundora MP. Antimicrobial Stewardship and Improved Antibiotic Utilization in the Pediatric Cardiac Intensive Care Unit. Pediatr Qual Saf 2024; 9:e710. [PMID: 38322295 PMCID: PMC10843537 DOI: 10.1097/pq9.0000000000000710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/22/2023] [Indexed: 02/08/2024] Open
Abstract
Background We developed a multidisciplinary antimicrobial stewardship team to optimize antimicrobial use within the Pediatric Cardiac Intensive Care Unit. A quality improvement initiative was conducted to decrease unnecessary broad-spectrum antibiotic use by 20%, with sustained change over 12 months. Methods We conducted this quality improvement initiative within a quaternary care center. PDSA cycles focused on antibiotic overuse, provider education, and practice standardization. The primary outcome measure was days of therapy (DOT)/1000 patient days. Process measures included electronic medical record order-set use. Balancing measures focused on alternative antibiotic use, overall mortality, and sepsis-related mortality. Data were analyzed using statistical process control charts. Results A significant and sustained decrease in DOT was observed for vancomycin and meropenem. Vancomycin use decreased from a baseline of 198 DOT to 137 DOT, a 31% reduction. Meropenem use decreased from 103 DOT to 34 DOT, a 67% reduction. These changes were sustained over 24 months. The collective use of gram-negative antibiotics, including meropenem, cefepime, and piperacillin-tazobactam, decreased from a baseline of 323 DOT to 239 DOT, a reduction of 26%. There was no reciprocal increase in cefepime or piperacillin-tazobactam use. Key interventions involved electronic medical record changes, including automatic stop times and empiric antibiotic standardization. All-cause mortality remained unchanged. Conclusions The initiation of a dedicated antimicrobial stewardship initiative resulted in a sustained reduction in meropenem and vancomycin usage. Interventions did not lead to increased utilization of alternative broad-spectrum antimicrobials or increased mortality. Future interventions will target additional broad-spectrum antimicrobials.
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Affiliation(s)
- Margot M. Hillyer
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine
| | - Preeti Jaggi
- Division of Infectious Disease, Department of Pediatrics, Emory University School of Medicine
| | - Nikhil K. Chanani
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine
| | | | - Hania Zaki
- Department of Pharmacy, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Michael P. Fundora
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine
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TULLY HANNAHM, DOHERTY DAN, WAINWRIGHT MARK. Mortality in pediatric hydrocephalus. Dev Med Child Neurol 2022; 64:112-117. [PMID: 34268734 PMCID: PMC8671148 DOI: 10.1111/dmcn.14975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 01/03/2023]
Abstract
AIM To clarify the extent to which medical comorbidities and goals-of-care decisions influence death among individuals with childhood-onset hydrocephalus. METHOD This was a retrospective cohort study of 1705 individuals (759 males, 946 females, mean age 11y 5mo, SD 6y 6mo, range 0-37y 7mo at last follow-up) with childhood-onset hydrocephalus, of whom 88 (5.2%) were deceased. Existing medical records, death records, and publicly available internet sources were analyzed. We estimated hazard ratios for putative risk factors through Cox regression based upon 10 529 person-years of data and quantitatively and qualitatively analyzed the circumstances surrounding each death. RESULTS Mortality did not differ statistically by demographic factors, although higher proportions of non-White and Hispanic individuals were deceased. Most deaths were related to medical comorbidities rather than hydrocephalus itself. Of the 14 deaths directly related to hydrocephalus, seven were caused by shunt complications and four occurred after decisions to forgo treatment, apparently in response to poor outcomes predicted by the medical team. Half the deaths were preceded by shifts to comfort-based care; however, these decisions appeared to substantially change the patient's clinical trajectory only half the time. INTERPRETATION Children are more likely to die with, rather than from, hydrocephalus. Our results emphasize the complexities of medical decision-making and the influence of clinicians in guiding these choices.
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Affiliation(s)
- HANNAH M TULLY
- Division of Pediatric Neurology, Seattle Children’s Hospital, Seattle, WA,Department of Neurology, University of Washington, Seattle, WA,Center for Integrated Brain Research, Seattle Children’s Research Institute, Seattle, WA
| | - DAN DOHERTY
- Center for Integrated Brain Research, Seattle Children’s Research Institute, Seattle, WA,Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA, USA
| | - MARK WAINWRIGHT
- Division of Pediatric Neurology, Seattle Children’s Hospital, Seattle, WA,Department of Neurology, University of Washington, Seattle, WA,Center for Integrated Brain Research, Seattle Children’s Research Institute, Seattle, WA
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Wu ET, Wang CC, Huang SC, Chen CH, Jou ST, Chen YC, Wu MH, Lu FL. End-of-Life Care in Taiwan: Single-Center Retrospective Study of Modes of Death. Pediatr Crit Care Med 2021; 22:733-742. [PMID: 33767073 DOI: 10.1097/pcc.0000000000002715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Medical advances and the National Health Insurance coverage in Taiwan mean that mortality in the PICU is low. This study describes change in modes of death and end-of-life care in a single center, 2011-2017. SETTING Multidisciplinary PICU in a tertiary referral Children's Hospital in Taiwan. PATIENTS There were 316 deaths in PICU patients. INTERVENTIONS Palliative care consultation in the PICU service occurred after the 2013 "Hospice Palliative Care Act" revision. MEASUREMENTS AND MAIN RESULTS In the whole cohort, 22 of 316 patients (7%) were determined as "death by neurologic criteria". There were 94 of 316 patients (30%) who had an event needing cardiopulmonary resuscitation within 24 hours of death: 17 of these patients (17/94; 18%) died after failed cardiopulmonary resuscitation without a do-not-resuscitate order, and the other 77 of 94 patients (82%) had a do-not-resuscitate order after cardiopulmonary resuscitation. Overall, there were 200 of 316 patients (63%) who had a do-not-resuscitate order and were entered into the palliative program: 169 of 200 (85%) died after life-sustaining treatment was limited, and the other 31 of 200 (15%) died after life-sustaining treatment was withdrawn. From 2011 to 2017, the time-trend in end-of-life care showed the following associations: 1) a decrease in PICU mortality utilization rate, from 22% to 7% (p < 0.001); 2) a decrease in use of catecholamine infusions after do-not-resuscitate consent, from 87% to 47% (p = 0.001), in patients having limitation in life-sustaining treatment; and 3) an increase in withdrawal of life-sustaining treatment, from 4% to 31% (p < 0.001). CONCLUSIONS In our practice in a single PICU-center in Taiwan, we have seen that the integration of a palliative care consultation service, developed after the revision of a national "Palliative Care Act," was associated with increased willingness to accept withdrawal of life-sustaining treatment and a lowered PICU care intensity at the end-of-life.
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Affiliation(s)
- En-Ting Wu
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Ching-Chia Wang
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Chieh-Ho Chen
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Yih-Charng Chen
- Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
| | - Frank Leigh Lu
- Department of Pediatrics, National Taiwan University Children's Hospital and College of Medicine, Taipei, Taiwan
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Moynihan KM, Heith CS, Snaman JM, Smith-Parrish M, Bakas A, Ge S, Cerqueira AV, Bailey V, Beke D, Wolfe J, Morell E, Gauvreau K, Blume ED. Palliative Care Referrals in Cardiac Disease. Pediatrics 2021; 147:peds.2020-018580. [PMID: 33579811 DOI: 10.1542/peds.2020-018580] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES With evidence of benefits of pediatric palliative care (PPC) integration, we sought to characterize subspecialty PPC referral patterns and end of life (EOL) care in pediatric advanced heart disease (AHD). METHODS In this retrospective cohort study, we compared inpatient pediatric (<21 years) deaths due to AHD in 2 separate 3-year epochs: 2007-2009 (early) and 2015-2018 (late). Demographics, disease burden, medical interventions, mode of death, and hospital charges were evaluated for temporal changes and PPC influence. RESULTS Of 3409 early-epoch admissions, there were 110 deaths; the late epoch had 99 deaths in 4032 admissions. In the early epoch, 45 patients (1.3% admissions, 17% deaths) were referred for PPC, compared with 146 late-epoch patients (3.6% admissions, 58% deaths). Most deaths (186 [89%]) occurred in the cardiac ICU after discontinuation of life-sustaining therapy (138 [66%]). Medical therapies included ventilation (189 [90%]), inotropes (184 [88%]), cardiopulmonary resuscitation (68 [33%]), or mechanical circulatory support (67 [32%]), with no temporal difference observed. PPC involvement was associated with decreased mechanical circulatory support, ventilation, inotropes, or cardiopulmonary resuscitation at EOL, and children were more likely to be awake and be receiving enteral feeds. PPC involvement increased advance care planning, with lower hospital charges on day of death and 7 days before (respective differences $5058 [P = .02] and $25 634 [P = .02]). CONCLUSIONS Pediatric AHD deaths are associated with high medical intensity; however, children with PPC consultation experienced substantially less invasive interventions at EOL. Further study is warranted to explore these findings and how palliative care principles can be better integrated into care.
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Affiliation(s)
- Katie M Moynihan
- Departments of Cardiology and .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Catherine S Heith
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Jennifer M Snaman
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Melissa Smith-Parrish
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Anna Bakas
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Valerie Bailey
- Cardiovascular and Critical Care Nursing Patient Services and
| | - Dorothy Beke
- Cardiovascular and Critical Care Nursing Patient Services and
| | - Joanne Wolfe
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts.,Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Emily Morell
- Division of Cardiology, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Kimberlee Gauvreau
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Elizabeth D Blume
- Departments of Cardiology and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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Morell E, Moynihan K, Wolfe J, Blume ED. Palliative care and paediatric cardiology: current evidence and future directions. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:502-510. [PMID: 31126897 DOI: 10.1016/s2352-4642(19)30121-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/20/2019] [Accepted: 02/27/2019] [Indexed: 12/24/2022]
Abstract
Although outcomes for children with heart disease have improved substantially over the past several decades, heart disease remains one of the leading causes of paediatric mortality. For children who progress to advanced heart disease, disease morbidity is high, with many children requiring multiple surgical interventions and long-term intensive care hospitalisations. Care for children with advanced heart disease requires a multidisciplinary approach, and opportunities for earlier integration of palliative care are being explored. This Viewpoint summarises the relevant literature over the past decade. We also identify gaps in parent and provider understanding of prognosis and communication, propose indications for palliative care consultation in paediatric advanced heart disease, and summarise attitudes and perceived barriers to palliative care consultation. Areas for additional research that we identify include paediatric cardiologist education, parental distress, socioeconomic disparities, and patient-reported outcomes. Interdisciplinary clinical and research efforts are required to further advance the field and improve integration of palliative care in the care of children with heart disease.
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Affiliation(s)
- Emily Morell
- Division of Pediatric Critical Care, UCSF Benioff Children's Hospitals, San Francisco, CA, USA
| | - Katie Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Joanne Wolfe
- Pediatric Palliative Care, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
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