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Affiliation(s)
- Neethi P Pinto
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Chris Feudtner
- Division of General Pediatrics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Medical Ethics and Health Policy, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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2
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Miller AG, Rotta AT. Flow of Change: Unmasking Variability in Respiratory Support for Pediatric Critical Asthma. Ann Am Thorac Soc 2024; 21:547-549. [PMID: 38557423 PMCID: PMC10995544 DOI: 10.1513/annalsats.202401-110ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Affiliation(s)
- Andrew G Miller
- Division of Pediatric Critical Care Medicine and
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
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3
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Rogerson CM, White BR, Smith M, Hogan AH, Abu-Sultaneh S, Carroll CL, Shein SL. Institutional Variability in Respiratory Support Use for Pediatric Critical Asthma: A Multicenter Retrospective Study. Ann Am Thorac Soc 2024; 21:612-619. [PMID: 38241011 PMCID: PMC10995549 DOI: 10.1513/annalsats.202309-807oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/18/2024] [Indexed: 04/04/2024] Open
Abstract
Rationale: Over 20,000 children are hospitalized in the United States for asthma every year. Although initial treatment guidelines are well established, there is a lack of high-quality evidence regarding the optimal respiratory support devices for these patients.Objectives: The objective of this study was to evaluate institutional and temporal variability in the use of respiratory support modalities for pediatric critical asthma.Methods: We conducted a retrospective cohort study using data from the Virtual Pediatrics Systems database. Our study population included children older than 2 years old admitted to a VPS contributing pediatric intensive care unit from January 2012 to December 2021 with a primary diagnosis of asthma or status asthmaticus. We evaluated the percentage of encounters using a high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), noninvasive bilevel positive pressure ventilation (NIV), and invasive mechanical ventilation (IMV) for all institutions, then divided institutions into quintiles based on the volume of patients. We created logistic regression models to determine the influence of institutional volume and year of admission on respiratory support modality use. We also conducted time-series analyses using Kendall's tau.Results: Our population included 77,115 patient encounters from 163 separate institutions. Institutional use of respiratory modalities had significant variation in HFNC (28.3%, interquartile range [IQR], 11.0-49.0%; P < 0.01), CPAP (1.4%; IQR, 0.3-4.3%; P < 0.01), NIV (8.6%; IQR, 3.5-16.1%; P < 0.01), and IMV (5.1%; IQR, 3.1-8.2%; P < 0.01). Increased institutional patient volume was associated with significantly increased use of NIV (odds ratio [OR], 1.33; 1.29-1.36; P < 0.01) and CPAP (OR, 1.20; 1.15-1.25; P < 0.01), and significantly decreased use of HFNC (OR, 0.80; 0.79-0.81; P < 0.01) and IMV (OR, 0.82; 0.79-0.86; P < 0.01). Time was also associated with a significant increase in the use of HFNC (11.0-52.3%; P < 0.01), CPAP (1.6-5.4%; P < 0.01), and NIV (3.7-21.2%; P < 0.01), whereas there was no significant change in IMV use (6.1-4.0%; P = 0.11).Conclusions: Higher-volume centers are using noninvasive positive pressure ventilation more frequently for pediatric critical asthma and lower frequencies of HFNC and IMV. Treatment with HFNC, CPAP, and NIV for this population is increasing in the last decade.
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Affiliation(s)
- Colin M. Rogerson
- Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Benjamin R. White
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Michele Smith
- Division of Critical Care Medicine, University of Rochester Medical Center, Rochester, New York
| | - Alexander H. Hogan
- Division of Hospital Medicine, Connecticut Children’s Medical Center, Hartford, Connecticut
| | - Samer Abu-Sultaneh
- Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Christopher L. Carroll
- Department of Pediatrics, Wolfson Children’s, University of Florida, Jacksonville, Florida; and
| | - Steven L. Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children’s Hospital, Cleveland, Ohio
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4
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Miller AG, Rehder KJ, Rotta AT. High-flow nasal cannula in critical asthma: Time for the respiratory therapists to drive care! Pediatr Pulmonol 2023; 58:3369-3371. [PMID: 37642278 DOI: 10.1002/ppul.26661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/19/2023] [Indexed: 08/31/2023]
Affiliation(s)
| | - Kyle J Rehder
- Duke University Medical Center, Durham, North Carolina, USA
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5
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Lopez M, Wilson M, Cobbina E, Kaufman D, Fluitt J, Grainger M, Ruiz R, Abudukadier G, Tiras M, Carlson B, Spaid J, Falsone K, Cocjin I, Moretti A, Vercio C, Tinsley C, Chandnani HK, Samayoa C, Cianci C, Pappas J, Chang NY. Decreasing ICU and Hospital Length of Stay through a Standardized Respiratory Therapist-driven Electronic Clinical Care Pathway for Status Asthmaticus. Pediatr Qual Saf 2023; 8:e697. [PMID: 38058471 PMCID: PMC10697623 DOI: 10.1097/pq9.0000000000000697] [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: 12/20/2022] [Accepted: 09/07/2023] [Indexed: 12/08/2023] Open
Abstract
Introduction Status asthmaticus (SA) is a cause of many pediatric hospitalizations. This study sought to evaluate how a standardized asthma care pathway (ACP) in the electronic medical record impacted the length of stay (LOS). Methods An interdisciplinary team internally validated a standardized respiratory score for patients admitted with SA to a 25-bed pediatric intensive care unit (PICU) at a tertiary children's hospital. The respiratory score determined weaning schedules for albuterol and steroid therapies. In addition, pharmacy and information technology staff developed an electronic ACP within our electronic medical record system using best practice alerts. These best practice alerts informed staff to initiate the pathway, wean/escalate treatment, transition to oral steroids, transfer level of care, and complete discharge education. The PICU, stepdown ICU (SD ICU), and acute care units implemented the clinical pathway. Pre- and postintervention metrics were assessed using process control charts and compared using Welch's t tests with a significance level of 0.05. Results Nine hundred two consecutive patients were analyzed (598 preintervention, 304 postintervention). Order set utilization significantly increased from 68% to 97% (P < 0.001), PICU LOS decreased from 38.4 to 31.1 hours (P = 0.013), and stepdown ICU LOS decreased from 25.7 to 20.9 hours (P = 0.01). Hospital LOS decreased from 59.5 to 50.7 hours (P = 0.003), with cost savings of $1,215,088 for the patient cohort. Conclusions Implementing a standardized respiratory therapist-driven ACP for children with SA led to significantly increased order set utilization and decreased ICU and hospital LOS. Leveraging information technology and standardized pathways may improve care quality, outcomes, and costs for other common diagnoses.
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Affiliation(s)
- Merrick Lopez
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michele Wilson
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Ekua Cobbina
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Danny Kaufman
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Julie Fluitt
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michele Grainger
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Robert Ruiz
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Gulixian Abudukadier
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michael Tiras
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Bronwyn Carlson
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Jeane Spaid
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Kim Falsone
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Invest Cocjin
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Anthony Moretti
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Chad Vercio
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
- Department of Pediatrics, Riverside University Health System, Moreno Valley, Calif
| | - Cynthia Tinsley
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Harsha K. Chandnani
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Carlos Samayoa
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - Carissa Cianci
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - James Pappas
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - Nancy Y. Chang
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
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Magner K, Mikhailov T, Simpson P, Anderson L, Buchman B, Gedeit R, Margolis D, Meyer MT. Dexmedetomidine for sedation during hematopoietic stem cell harvest apheresis and leukapheresis in the PICU: Guideline development. Transfus Apher Sci 2023; 62:103525. [PMID: 36058778 DOI: 10.1016/j.transci.2022.103525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Hematopoietic stem cell (HSC) harvest apheresis and leukapheresis are performed in the pediatric intensive care unit (PICU) for high-risk pediatric patients who require procedural sedation. Patients need central access either with their own central lines, ports or require apheresis catheter (CVL) placement. Previously, patients were either awake or emerging from sedation on PICU admission. Uncertainty regarding procedural sedation plans caused delays initiating sedation and apheresis. A guideline was developed to standardize Dexmedetomidine (DEX) for procedural sedation. We investigated if guideline implementation would improve efficiency during PICU admission as demonstrated by shorter time intervals for initiation of sedation, apheresis, PICU length of stay and less alternative sedating medication. METHODS Data was collected retrospectively from electronic health records of preguideline and post-guideline patients who were admitted to the PICU for sedated apheresis. We compared demographic and clinical characteristics, time intervals for sedation, apheresis, PICU length of stay, and sedation agents between the two groups using Fisher Exact tests and Mann-Whitney tests, as appropriate. RESULTS The groups did not differ in age or weight at the time of apheresis. All intervals of time compared were shorter post-guideline. Time intervals from admission to start of sedation, admission to start of apheresis, and admission to end of apheresis were statistically significantly different. The type and number of alternative sedating medications administered did not differ between the two groups. CONCLUSION This guideline implementation improved efficiency during PICU admission. This study might have been too small to demonstrate statistically significant differences in other time intervals studied.
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Affiliation(s)
- Kristin Magner
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA.
| | - Theresa Mikhailov
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - Pippa Simpson
- Department of Pediatrics, Division of Quantitative Health Sciences. Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lynnette Anderson
- Pediatric Hematology/Oncology, Children's Wisconsin, Milwaukee, WI, USA
| | - Bo Buchman
- Pediatric Hematology/Oncology, Children's Wisconsin, Milwaukee, WI, USA
| | - Rainer Gedeit
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - David Margolis
- Department of Pediatrics, Division of Hematology/Oncology, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
| | - Michael T Meyer
- Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin and Children's Wisconsin, Milwaukee, WI, USA
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Valentine K, Kummick J. PICU Pharmacology. Pediatr Clin North Am 2022; 69:509-529. [PMID: 35667759 DOI: 10.1016/j.pcl.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The care of the critically-ill child often includes medications used to optimize organ function, treat infections, and provide comfort. Pediatric pharmacology has some key differences that should be leveraged for safe pharmacologic management.
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Affiliation(s)
- Kevin Valentine
- Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Suite 4900, Indianapolis, IN 46202, USA.
| | - Janelle Kummick
- Butler University College of Pharmacy and Health Sciences, Riley Hospital for Children, 705 Riley Hospital Drive, Room W6111, Indianapolis, IN 46202, USA
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Cox C, Patel K, Cantu R, Akmyradov C, Irby K. Hypokalemia Measurement and Management in Patients With Status Asthmaticus on Continuous Albuterol. Hosp Pediatr 2022; 12:198-204. [PMID: 35018439 DOI: 10.1542/hpeds.2021-006265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Status asthmaticus is commonly treated in pediatric patients by using continuous albuterol, which can cause hypokalemia. The primary aim of this study was to determine if serial potassium monitoring is necessary by examining treatment frequency of hypokalemia. METHODS This retrospective analysis was performed in 185 pediatric patients admitted with status asthmaticus requiring continuous albuterol between 2017 and 2019. All patients were placed on intravenous fluids containing potassium. The primary outcome measure was the treatment of hypokalemia in relation to the number of laboratory draws for potassium levels. The secondary outcome measure was hypokalemia frequency and relation to the duration and initial dose of continuous albuterol. RESULTS Included were 156 patients with 420 laboratory draws (average, 2.7 per patient) for potassium levels. The median lowest potassium level was 3.40 mmol/L (interquartile range, 3.2-3.7). No correlation was found between initial albuterol dose and lowest potassium level (P = .52). Patients with hypokalemia had a mean albuterol time of 12.32 (SD, 15.76) hours, whereas patients without hypokalemia had a mean albuterol time of 11.50 (SD, 12.53) hours (P = .29). Potassium levels were treated 13 separate times. CONCLUSIONS The number of laboratory draws for potassium levels was high in our cohort, with few patients receiving treatment for hypokalemia beyond the potassium routinely added to maintenance fluids. Length of time on albuterol and dose of albuterol were not shown to increase the risk of hypokalemia. Serial laboratory measurements may be decreased to potentially reduce health care costs, pain, and anxiety surrounding needlesticks.
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Affiliation(s)
- Courtney Cox
- Divisions of Critical Care Medicine and.,Arkansas Children's Hospital, Little Rock, Arkansas
| | | | - Rebecca Cantu
- Hospital Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and University of Arkansas for Medical Sciences, Little Rock, Arkansas; and.,Arkansas Children's Hospital, Little Rock, Arkansas
| | | | - Katherine Irby
- Divisions of Critical Care Medicine and.,Arkansas Children's Hospital, Little Rock, Arkansas
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Karube T, Goins T, Karsies TJ, Gee SW. Reducing Avoidable Transfer Delays in the Pediatric Intensive Care Unit for Status Asthmaticus Patients. Pediatr Qual Saf 2022; 7:e527. [PMID: 35071962 PMCID: PMC8782102 DOI: 10.1097/pq9.0000000000000527] [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: 04/22/2021] [Accepted: 10/23/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Status asthmaticus (acute severe asthma) is one of the most common reasons for Pediatric Intensive Care Unit (PICU) admission. Accordingly, ensuring optimal throughput for patients admitted with status asthmaticus is essential for optimizing PICU capacity. Few studies specifically address effective methods to reduce delays related to PICU discharge. This project aimed to identify and reduce avoidable delays in PICU discharge for status asthmaticus patients. METHODS This quality improvement project focused on reducing transfer delays for status asthmaticus patients admitted to the PICU at a freestanding academic children's hospital. We standardized the transfer criteria, identified barriers to an efficient transfer, and implemented multidisciplinary interventions. The primary aim was to decrease the average duration from fulfilling the transfer criteria to PICU discharge by 15% from the baseline within 8 months of implementation. The balancing measure was readmissions to the PICU for asthma exacerbations within 24 hours from PICU discharge. RESULTS The analysis included 623 patients. Following interventions, the time from fulfilling transfer criteria to PICU discharge decreased from 9.8 hours to 6.8 hours, a 30.6% reduction from baseline. Improvements were sustained for 6 months. In the preintervention group, three patients were readmitted to the PICU within 24 hours of transferring out of the PICU, but no patient was readmitted during the postintervention period. CONCLUSIONS Standardizing transfer criteria and implementing multidisciplinary strategies can reduce avoidable PICU discharge delays for patients with status asthmaticus. The application of a similar approach could potentially reduce avoidable delays for other conditions in the PICU.
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Affiliation(s)
- Takaharu Karube
- From the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Theresa Goins
- Pediatric Intensive Care Unit Clinical Lead Respiratory Therapist, Nationwide Children’s Hospital, Columbus, Ohio
| | - Todd J. Karsies
- From the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Samantha W. Gee
- From the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
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Flaherty MR, Whalen K, Lee J, Duran C, Alshareef O, Yager P, Cummings B. Implementation of a Nurse-Driven Asthma Pathway in the Pediatric Intensive Care Unit. Pediatr Qual Saf 2021; 6:e503. [PMID: 34934882 PMCID: PMC8677970 DOI: 10.1097/pq9.0000000000000503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/31/2021] [Indexed: 12/01/2022] Open
Abstract
Asthma is one of the most common conditions requiring admission to a pediatric intensive care unit. Dosing and weaning medications, particularly bronchodilators, are highly variable, and evidence-based weaning algorithms for clinicians are lacking in this setting. METHODS Patients admitted to a quaternary pediatric intensive care unit diagnosed with acute severe asthma were evaluated for time spent receiving continuous albuterol therapy, the length of stay in the intensive unit care unit, and the length of stay in the hospital. We developed an asthma pathway and continuous bronchodilator weaning algorithm to be used by bedside nurses. We then implemented two major Plan-Do-Study-Act cycles to facilitate the use of the pathway. They included implementing the algorithm and then integrating it as a clinical decision support tool in the electronic medical record. We used standard statistics and quality improvement methodology to analyze results. RESULTS One-hundred twenty-six patients met inclusion criteria during the study period, with 32 during baseline collection, 60 after weaning algorithm development and implementation, and 34 after clinical decision support implementation. Using quality improvement methodology, hours spent receiving continuous albuterol decreased from a mean of 43.6 to 28.6 hours after clinical decision support development. There were no differences in length of stay using standard statistics and QI methodology. CONCLUSION Protocolized asthma management in the intensive care unit setting utilizing a multidisciplinary approach and clinical decision support tools for bedside nursing can reduce time spent receiving continuous albuterol and may lead to improved patient outcomes.
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Affiliation(s)
- Michael R. Flaherty
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
- Harvard Medical School, Boston, Mass
| | - Kimberly Whalen
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
| | - Ji Lee
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
| | - Carlos Duran
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
- Harvard Medical School, Boston, Mass
| | - Ohood Alshareef
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
| | - Phoebe Yager
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
- Harvard Medical School, Boston, Mass
| | - Brian Cummings
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
- Harvard Medical School, Boston, Mass
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Siraj S, Stark W, McKinley SD, Morrison JM, Sochet AA. The bronchiolitis severity score: An assessment of face validity, construct validity, and interobserver reliability. Pediatr Pulmonol 2021; 56:1739-1744. [PMID: 33629813 DOI: 10.1002/ppul.25337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/02/2021] [Accepted: 02/20/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess face validity, interobserver reliability, and the ability to discriminate escalations of care within 24-h of admission (late rescues) for the bronchiolitis severity score (BSS) for children hospitalized for acute bronchiolitis. HYPOTHESES The BSS will yield variable face validity, have clinically relevant interobserver reliability (kappa > 0.7), and distinguish late rescues during hospitalization. METHODS We performed a combined retrospective and prospective, mixed methods study where (1) interobserver agreement was prospectively assessed by overall and subcategory congruence (kappa) calculations, (2) face value were qualitatively assessed from aggregate questionnaire responses, and (3) construct validity for late rescues were assessed using receiver operator characteristic (ROC) curve analyses. RESULTS Face validity, assessed from 39 questionnaire respondents, were generally positive for BSS utility, reliability, and usability. The BSS exhibited weak interobserver reliability (kappa = 0.22, 95% confidence interval [CI]: 0.11-0.31) calculated from 72 sequential, blinded calculations. Retrospectively, 181 children less than 2 years of age admitted to the general pediatric ward for acute bronchiolitis from November 2017 to April 2019 were identified of which 18 (9.9%) experienced late rescues. Admission BSS values were no different for children with and without late rescues (6[3,6] vs. 4[3,6]; p = .09). An ROC curve analysis revealed an area under the curve of 0.61 (95% CI: 0.48-0.75; threshold ≥6 with sensitivity = 56%, specificity = 69%) for BSS to discriminate late rescues. CONCLUSION Although clinicians expressed favorable perceptions of BSS face and content validity, we noted weak interobserver reliability and limited construct validity. Further development and validation are needed to strengthen the BSS before routine use.
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Affiliation(s)
- Shaila Siraj
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA.,Division of Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Wayne Stark
- Divisions of Emergency Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Scott Daniel McKinley
- Division of Pulmonlogy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - John Michael Morrison
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Anthony Alexander Sochet
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
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Miksa M, Kaushik S, Antovert G, Brown S, Ushay HM, Katyal C. Implementation of a Critical Care Asthma Pathway in the PICU. Crit Care Explor 2021; 3:e0334. [PMID: 33604577 PMCID: PMC7886451 DOI: 10.1097/cce.0000000000000334] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Acute asthma management has improved significantly across hospitals in the United States due to implementation of standardized care pathways. Management of severe acute asthma in ICUs is less well studied, and variations in management may delay escalation and/or deescalation of therapies and increase length of stay. In order to standardize the management of severe acute asthma in our PICU, a nurse- and respiratory therapist-driven critical care asthma pathway was designed, implemented, and tested. DESIGN Cross-sectional study of severe acute asthma at baseline followed by implementation of a critical care asthma pathway. SETTING Twenty-six-bed urban quaternary PICU within a children's hospital. PATIENTS Patients 24 months to 18 years old admitted to the PICU in status asthmaticus. Patients with severe bacterial infections, chronic lung disease, heart disease, or immune disorders were excluded. INTERVENTIONS Implementation of a nurse- and respiratory therapist-driven respiratory scoring tool and critical care asthma pathway with explicit escalation/deescalation instructions. MEASUREMENTS AND MAIN RESULTS Primary outcome was PICU length of stay. Secondary outcomes were time to resolution of symptoms and hospital length of stay. Compliance approached 90% for respiratory score documentation and critical care asthma pathway adherence. Severity of illness at admission and clinical baseline characteristics were comparable in both groups. Pre intervention, the median ICU length of stay was 2 days (interquartile range, 1-3 d) with an overall hospital length of stay of 4 days (interquartile range, 3-6 d) (n = 74). After implementation of the critical care asthma pathway, the ICU length of stay was 1 day (interquartile range, 1-2 d) (p = 0.0013; n = 78) with an overall length of stay of 3 days (interquartile range, 2-3.75 d) (p < 0.001). The time to resolution of symptoms was reduced from a median of 66.5 hours in the preintervention group to 21 hours in the postintervention compliant group (p = 0.036). CONCLUSIONS The use of a structured critical care asthma pathway, driven by an ICU nurse and respiratory therapist, is associated with faster resolution of symptoms, decreased ICU, and overall hospital lengths of stay in children admitted to an ICU for severe acute asthma.
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Affiliation(s)
- Michael Miksa
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Shubhi Kaushik
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Gerald Antovert
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Sakar Brown
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - H Michael Ushay
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Chhavi Katyal
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
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13
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Ryan KS, Son S, Roddy M, Siraj S, McKinley SD, Nakagawa TA, Sochet AA. Pediatric asthma severity scores distinguish suitable inpatient level of care for children admitted for status asthmaticus. J Asthma 2019; 58:151-159. [PMID: 31608716 DOI: 10.1080/02770903.2019.1680998] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objective: To determine if the Pediatric Asthma Severity Score (PASS) can distinguish "late-rescues" (transfer to the pediatric intensive care unit [PICU] within 24-hours of general pediatric floor admission), "PICU readmissions" (readmission within 24-h after transfer to a lower inpatient level of care), and unplanned 30-day hospital readmission in children admitted with status asthmaticus.Methods: We performed a single center, retrospective cohort study in 328 children admitted for asthma exacerbation aged 5-18 years from May 2015 to October 2017. We sought to determine if PASS values preceding admission from the emergency department or transfer to the general pediatric unit will be greater in children with late rescues and PICU readmissions and if a cutoff PASS values exist to discriminate these events prior to intrafacility transfer.Results: Nine (5%) late-rescues and 5 (3%) PICU readmissions accounted for 14/328 (4%) composite outcomes. PASS values were greater in children with these events (8 [IQR:5-8] vs. 5 [IQR:3-6], p < .01). Logistic regression of PASS on composite outcome yielded an odds ratio of 1.4 (1.1-1.8, p < .01) and ROC curve of PASS on a composite outcome yielded an AUC of 0.74 (0.61-0.87) with a threshold of ≥ 9. Nine (3%) children experienced unplanned 30-day hospital readmissions but PASS preceding hospital discharge was neither discriminative nor associated with hospital readmission.Conclusions: PASS values ≥ 9 identify children at increased risk for late-rescue and PICU readmission. Applied with traditionally criteria for selection of inpatient level of care, PASS may assist providers in reducing acute inpatient disposition errors.
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Affiliation(s)
- Kelsey S Ryan
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - Sorany Son
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Meghan Roddy
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Shaila Siraj
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Pediatrics, University of South Florida, Tampa, FL, USA.,School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Thomas A Nakagawa
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Anthony A Sochet
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Pediatrics, University of South Florida, Tampa, FL, USA.,School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Miller AG, Haynes KE, Gates RM, Zimmerman KO, Heath TS, Bartlett KW, McLean HS, Rehder KJ. A Respiratory Therapist-Driven Asthma Pathway Reduced Hospital Length of Stay in the Pediatric Intensive Care Unit. Respir Care 2019; 64:1325-1332. [PMID: 31088987 DOI: 10.4187/respcare.06626] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Asthma is a common reason for admissions to the pediatric intensive care unit (PICU). Since June 2014, our institution has used a pediatric asthma clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist-driven bronchodilator weaning based on the Modified Pulmonary Index Score (MPIS). This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however, the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatic patients admitted to the PICU. METHODS We retrospectively reviewed the medical records of all pediatric asthma subjects 2-17 y old admitted to our PICU before and after pathway initiation. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the chi-square test for categorical data, the t test for normally distributed data, and the Mann-Whitney test for nonparametric data. RESULTS A total of 203 eligible subjects (49 in the pre-pathway group, 154 in the post group) were enrolled. There were no differences between groups for age, weight, gender, home medications, cause of exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS (4.4 [2.9-6.6] d vs 2.7 [1.6-4.0] d, P < .001), median PICU LOS (2.1 [1.3-4.0] d vs 1.6 [0.8-2.4] d, P = .003), and median time on continuous albuterol (39 [25-85] h vs 27 [13-42] h, P = .001). Significantly more subjects in the post-pathway group were placed on high-flow nasal cannula (32% vs 6%, P = .001) or noninvasive ventilation (10% vs 4%, P = .02). CONCLUSION The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in the use of high-flow nasal cannula and noninvasive ventilation after the implementation of this clinical pathway.
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Affiliation(s)
- Andrew G Miller
- Respiratory Care Services at Duke University Medical Center, Durham, North Carolina.
| | - Kaitlyn E Haynes
- Respiratory Care Services at Duke University Medical Center, Durham, North Carolina
| | - Rachel M Gates
- Respiratory Care Services at Duke University Medical Center, Durham, North Carolina
| | - Kanecia O Zimmerman
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Travis S Heath
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina
| | - Kathleen W Bartlett
- Division of Pediatric Hospital Medicine, Duke University Medical Center, Duke University Medical Center, Durham, North Carolina
| | - Heather S McLean
- Division of Pediatric Hospital Medicine, Duke University Medical Center, Duke University Medical Center, Durham, North Carolina
| | - Kyle J Rehder
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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