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Kang ES, Turkdogan S, Yeung JC. Disposition to pediatric intensive care unit post supraglottoplasty repair: a systematic review. J Otolaryngol Head Neck Surg 2023; 52:35. [PMID: 37106398 PMCID: PMC10136380 DOI: 10.1186/s40463-023-00622-z] [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: 08/22/2022] [Accepted: 01/28/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Patients undergoing supraglottoplasty are often routinely admitted post-operatively to the pediatric intensive care unit (PICU) due to rare but potentially fatal complications such as airway compromise. A systematic review was performed to determine the rate of post-operative PICU-level respiratory support required by pediatric patients following supraglottoplasty, to identify risk factors for patients who may benefit from post-operative PICU admission and limit unnecessary use of intensivist resources. REVIEW METHODS Key search terms 'supraglottoplasty' OR 'supraglottoplasties' were queried on three databases: CINHAL, Medline and Embase. Inclusion criteria were pediatric patients under 18 years of age who underwent a supraglottoplasty procedure with either an admission to PICU or requirement for PICU-level respiratory support. Risk of bias was assessed by two independent reviewers using QUADAS-2. Findings were critically appraised by three independent reviewers and pooled proportions of criteria meeting PICU admission were calculated for meta-analysis. RESULTS Nine studies met inclusion criteria, totaling 922 patients. Age at time of surgery ranged from 19 days to 15.7 years with mean age of 5.65 months. A weighted pooled estimate suggested that 19% (95% CI 14-24%) of patients who underwent supraglottoplasty required PICU-admission. The included studies revealed several patient and surgical factors have been linked to postoperative respiratory issues requiring PICU admission, including: neurological disease, perioperative oxygen saturation < 95%, prolonged surgical time and age < 2 months. CONCLUSIONS This study found that the majority of supraglottoplasty patients do not require significant postoperative respiratory support and suggests that routine PICU admission of these patients may be avoided by careful patient selection. Given the wide heterogeneity of outcome measures, further studies are needed to determine the ideal PICU admission criteria following supraglottoplasty.
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Affiliation(s)
- Esther ShinHyun Kang
- Faculty of Medicine, McGill University, Montreal, Canada
- Department of Anesthesia, McGill University Health Centre, Montreal, Canada
| | - Sena Turkdogan
- Faculty of Medicine, McGill University, Montreal, Canada
- Department of Otolaryngology - Head and Neck Surgery, McGill University Health Centre, Montreal, Canada
| | - Jeffrey C Yeung
- Faculty of Medicine, McGill University, Montreal, Canada.
- Department of Otolaryngology - Head and Neck Surgery, McGill University Health Centre, Montreal, Canada.
- Department of Pediatric Surgery, Montreal Children's Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada.
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Yetneberk T, Firde M, Tiruneh A, Fentie Y, Tariku M, Mihret G, Moore J. Incidence of unplanned intensive care unit admission following surgery and associated factors in Amhara regional state hospitals. Sci Rep 2022; 12:20121. [PMID: 36418456 PMCID: PMC9684567 DOI: 10.1038/s41598-022-24571-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022] Open
Abstract
Unplanned postoperative critical care admission poses a potential risk to patients and places unanticipated pressure on clinical services and it has become an important parameter to assess patient safety in perioperative services. This study was aimed to determine the incidence of unplanned intensive care unit admission following surgery and the associated factors. A multi-center cross-sectional study was conducted on postoperative patients admitted to the ICU of three hospitals located in the Amhara region. Data were collected via a structured survey tool and analyzed using SPSS version 23 software with binary logistic regression analysis. The statistical significance to identify patient, anesthetic and surgical related factors in the preoperative, intraoperative, and postoperative period was < 0.05 for multivariable regression with a 95% confidence interval. Predominantly patients were admitted to the ICU in an unplanned manner. ASA status, preoperative hemoglobin (Hgb) level, intraoperative estimated blood loss, and adverse events occurring in the operating room were significantly associated with intensive care unit admission following surgery. Patients who had a low preoperative Hgb value were 35.1 times more likely to be admitted to the intensive care unit in an unplanned manner compared with their counterparts [(Adjust odds ratio (AOR) 35.16; CI 12.82, 96.44)]. Patients with ASA II and III were 19.4 and 16.2 times more likely to be admitted to ICU in an unplanned way compared to patients who had ASA I physical status [(AOR 51.79; CI 8.28, 323.94) (AOR 67.8 CI 14.68, 313.53)]. Unplanned ICU admission after surgery was high in this study, suggesting poor perioperative planning, risk stratification, and optimization of patients.
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Affiliation(s)
- Tikuneh Yetneberk
- grid.510430.3Department of Anesthesia, Debre Tabor University, Debre Tabor, Ethiopia
| | - Meseret Firde
- grid.510430.3Department of Anesthesia, Debre Tabor University, Debre Tabor, Ethiopia
| | - Abebe Tiruneh
- grid.510430.3Department of Anesthesia, Debre Tabor University, Debre Tabor, Ethiopia
| | - Yewlsew Fentie
- grid.510430.3Department of Anesthesia, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mequanent Tariku
- grid.510430.3Department of Gynecology and Obstetrics, Debre Tabor University, Debre Tabor, Ethiopia
| | - Gashaw Mihret
- grid.510430.3School of Medicine, Debre Tabor University, Debre Tabor, Ethiopia
| | - Jolene Moore
- grid.7107.10000 0004 1936 7291School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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Alshareef WA, Aldriweesh BA, Almutairi NK, Alsini AY, Zakzouk AS, Aljasser AI, Alammar AY. Adverse Respiratory Events After Pediatric Endoscopic Airway Surgeries. EAR, NOSE & THROAT JOURNAL 2022:1455613221128111. [PMID: 36112766 DOI: 10.1177/01455613221128111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
OBJECTIVE Perioperative risk stratification of pediatric patients undergoing airway intervention remains crucial in identifying those at a higher risk of requiring postoperative intensive care unit (ICU) care. Here we determined the likelihood of and possible risk factors for developing perioperative adverse respiratory events (PAREs) requiring ICU care after various pediatric endoscopic airway surgeries (EASs). METHODS We conducted a retrospective chart review of pediatric patients who were aged <18 years and underwent EAS between 2015 and 2021. Early postoperative adverse events within 24 h of surgery were recorded and analyzed. RESULTS Overall, 99 patients who underwent EAS were included. The age at the time of the intervention ranged from 8 months to 18 years. Fifty-eight patients, median age was 4.83 years, underwent papilloma debulking with no high likelihood of PARE in this patient subgroup (OR = 0.48; 0.16-1.44). Twenty-five patients, median age was 9.72 years, underwent balloon dilation of laryngotracheal stenosis with no increase in the likelihood of PARE in this patient population (OR = 2.02; 0.65-6.28). Early postoperative respiratory events occurred in 16 patients (16.2%). Most of these events (75%) manifested within 4 h after surgery. In a univariate analysis, intervention at the level of the subglottis or 2 or more laryngeal subsites increased the risk of PARE (OR = 6.57; 1.11-12.52 and OR = 3.73; 1.93-22.34, respectively). In a multivariate analysis, only intervention in the subglottic area maintained its effect (OR = 6.84; 1.82-25.65). CONCLUSION Respiratory adverse events following pediatric EAS are not uncommon, and the majority are encountered shortly after surgery. Intervention in the subglottic area was an independent predictor of PARE.
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Affiliation(s)
- Waleed A Alshareef
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Bshair A Aldriweesh
- Department of Otolaryngology-Head and Neck Surgery, King Fahad Specialist Hospital-Dammam, Dammam, Saudi Arabia
| | - Nasser K Almutairi
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
- Department of Otolaryngology-Head and Neck Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Albaraa Y Alsini
- Department of Otolaryngology, Head and Neck Surgery, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
| | - Abdulmajeed S Zakzouk
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Abdullah I Aljasser
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ahmed Y Alammar
- Department of Otolaryngology-Head and Neck Surgery, King Saud University Medical City, Riyadh, Saudi Arabia
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Risk factors associated with unplanned ICU admissions following paediatric surgery: A systematic review. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2022; 38. [PMID: 36101712 PMCID: PMC9442853 DOI: 10.7196/sajcc.2022.v38i2.504] [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] [Accepted: 06/20/2022] [Indexed: 11/24/2022] Open
Abstract
Background
Unplanned admissions to the intensive care unit (ICU) have important implications in the general management of patients. Research
in this area has been conducted in the adult and non-surgical population. To date, there is no systematic review addressing risk factors in the
paediatric surgical population.
Objectives
To synthesise the information from studies that explore the risk factors associated with unplanned ICU admissions following surgery
in children through a systematic review process.
Methods
We conducted a systematic review of published literature (PROSPERO registration CRD42020163766), adhering to the Preferred
Reporting of Observational Studies and Meta-Analysis (PRISMA) statement. The Population, Exposure, Comparator, Outcome (PECO) strategy
used was based on: population – paediatric population, exposure – risk factors, comparator – other, and outcome – unplanned ICU admission.
Data that reported on unplanned ICU admissions following paediatric surgery were extracted and analysed. Quality of the studies was assessed
using the Newcastle-Ottawa Scale.
Results
Seven studies were included in the data synthesis. Four studies were of good quality with the Newcastle-Ottawa Scale score ≥7 points.
The pooled prevalence (95% confidence interval) estimate of unplanned ICU stay was 2.69% (0.05 - 8.6%) and ranged between 0.06% and 8.3%.
Significant risk factors included abnormal sleep studies and the presence of comorbidities in adenotonsillectomy surgery. In the general surgical
population, younger age, comorbidities and general anaesthesia were significant. Abdominal surgery and ear, nose and throat (ENT) surgery
resulted in a higher risk of unplanned ICU admission. Owing to the heterogeneity of the data, a meta-analysis with risk prediction could not
be performed.
Conclusion
Significant patient, surgical and anaesthetic risk factors associated with unplanned ICU admission in children following surgery
are described in this systematic review. A combination of these factors may direct planning toward anticipation of the need for a higher level of
postoperative care. Further work to develop a predictive score for unplanned ICU stay is desirable.
Contributions of the study
Unplanned admissions to the intensive care unit (ICU) have been acknowledged as an overall marker of safety.[1] Awareness of this concept has
encouraged research to determine the incidence and risk factors of these occurrences. This research has been interrogated in a systematic review
process with beneficial conclusions drawn; however, these studies included adults and non-surgical patients.[2–4] To date, we have not been able to
find a systematic review addressing the risk factors associated with unplanned ICU admissions in paediatric surgical patients.
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Taylor KL, Frndova H, Szadkowski L, Joffe AR, Parshuram CS. Risk factors for unplanned paediatric intensive care unit admission after anaesthesia—an international multicentre study. Paediatr Child Health 2022; 27:333-339. [DOI: 10.1093/pch/pxac041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Unplanned intensive care unit (ICU) admissions are associated with near-miss events, morbidity, and mortality. We describe the rate, resource utilization, and outcomes of paediatric patients urgently admitted directly to ICU post-anaesthesia compared to other sources of unplanned ICU admissions.
Methods
We performed a secondary analysis of data from specialist paediatric hospitals in 7 countries. Patients urgently admitted to the ICU post-anaesthesia were combined and matched with 1 to 3 unique controls from unplanned ICU admissions from other locations by age and hospital. Demographic, clinical, and outcome variables were compared using the Wilcoxon rank-sum test for continuous variables and chi-square or Fisher’s exact test for categorical variables. The effect of admission sources on binary outcomes was estimated using univariable conditional logistic regression models with stratification by matched set of anaesthesia and non-anaesthesia admission sources.
Results
Most admissions were <1 year of age and for respiratory reasons. Admissions post-anaesthesia were shorter, occurred later in the day, and were more likely to be mechanically ventilated. Admissions post-anaesthesia were less likely to have had a previous ICU admission (4.8% compared to 11%, P=0.032) or PIM ‘high-risk diagnosis’ (9.5% versus 17.2%, P=0.035) but there was no difference in the number of subsequent ICU admissions. There was no difference in the PIM severity of illness score and no mortality difference between the groups.
Conclusions
Young children and respiratory indications dominated unplanned ICU admissions post-anaesthesia, which was more likely later in the day and with mechanical ventilation.
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Affiliation(s)
- Katherine L Taylor
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children , Toronto, Ontario , Canada
- Department of Anesthesia, University of Toronto , Toronto, Ontario , Canada
| | - Helena Frndova
- Department of Critical Care Medicine, Division of Critical Care Medicine, The Hospital for Sick Children , Toronto, Ontario , Canada
| | - Leah Szadkowski
- University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Ari R Joffe
- Division of Critical Care Medicine, Department of Pediatrics, University of Alberta , Edmonton, Alberta , Canada
| | - Christopher S Parshuram
- Department of Critical Care Medicine, Division of Critical Care Medicine, The Hospital for Sick Children , Toronto, Ontario , Canada
- Department of Critical Care Medicine, Department of Paediatrics, University of Toronto , Toronto, Ontario , Canada
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6
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Tsuboi K, Ninagawa J, Tsuboi N, Nakagawa S, Suzuki Y. Unplanned admission to pediatric intensive care after general anesthesia: A seven-year retrospective cohort study in a tertiary children's hospital. Paediatr Anaesth 2022; 32:56-61. [PMID: 34687108 DOI: 10.1111/pan.14313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 10/08/2021] [Accepted: 10/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thorough preoperative risk assessment and planning is key to improving patient safety in the perioperative period. Analysis of unplanned ICU admissions after general anesthesia has been validated as a measure of patient safety and its use as a quality initiative is recommended in many countries. AIMS The aims of this study were to determine the reasons for unplanned ICU admission, required interventions, and outcomes after general anesthesia in our hospital, as well as predictability and preventability of the events that led to admission with a view to improving anesthetic management. METHODS A single-center, retrospective cohort study in a tertiary children's hospital was performed. All patients under the age of 18 years admitted to our PICU between June 2014 and May 2021 were included. Unplanned ICU admission after general anesthesia was defined as an admission to the ICU either immediately postoperatively or after recovery room stay, which was not planned preoperatively. The reasons for ICU admission were classified as anesthesia-related, surgical, medical, or mixed. Required intervention, length of ICU stay, and patient outcome of each group, as well as preventability and predictability of the events were investigated. RESULTS There were 75 admissions, representing 0.23% of all general anesthesia procedures during the study period. "Anesthesia-related" was the major reason for admission of which the majority required observation only or transient respiratory support with a median ICU stay of two days. Most of the admissions for medical reasons required disease-specific interventions resulting in the longest ICU stays with a median of six days. A total of 19% of the admissions were preventable, where most of them were for anesthesia-related reasons, and 33% were predictable. Seven patients required cardiopulmonary resuscitation, of which one patient died, giving an observed mortality rate of 1.3% overall. All but one patient who died demonstrated no changes in the Pediatric Cerebral Performance Category (PCPC) scale. CONCLUSION "Anesthesia-related" was the leading reason for unplanned ICU admissions, of which the majority required only observation or transient respiratory support. All but one patient who died demonstrated no changes in the PCPC scale, presenting favorable outcome overall.
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Affiliation(s)
- Kaoru Tsuboi
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Jun Ninagawa
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Norihiko Tsuboi
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Yasuyuki Suzuki
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
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Badelt G, Goeters C, Becke-Jakob K, Deitmer T, Eich C, Höhne C, Stuck BA, Wiater A. S1-Leitlinie: Obstruktive Schlafapnoe im Rahmen von Tonsillenchirurgie mit oder ohne Adenotomie bei Kindern – perioperatives Management. SOMNOLOGIE 2021. [DOI: 10.1007/s11818-021-00303-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Badelt G, Goeters C, Becke-Jakob K, Deitmer T, Eich C, Höhne C, Stuck BA, Wiater A. [German S1 guideline: obstructive sleep apnea in the context of tonsil surgery with or without adenoidectomy in children-perioperative management]. HNO 2020; 69:3-13. [PMID: 33354732 DOI: 10.1007/s00106-020-00970-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
Otolaryngologic surgery is one of the most frequent operative interventions performed in children. Tonsil surgery with or without adenoidectomy due to hyperplasia of the tonsils and adenoids with obstruction of the upper airways with or without tympanic ventilation disorder is the most common of these procedures. Children with a history of sleep apnoea (OSA) suffer from a significantly increased risk of perioperative respiratory complications. Cases of death and severe permanent neurologic damage have been reported due to apnoea and increased opioid sensitivity. The current guideline represents a pragmatic risk-adjusted approach. Patients with confirmed or suspected OSA should be treated perioperatively according to their individual risks and requirements, in order to avoid severe permanent damage.
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Affiliation(s)
- G Badelt
- Klinik für Anästhesie und Kinderanästhesie, Krankenhaus Barmherzige Brüder Regensburg, Klinik St. Hedwig, Steinmetzstraße 1-3, 93049, Regensburg, Deutschland. .,Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland.
| | - C Goeters
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - K Becke-Jakob
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - T Deitmer
- Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e. V. (DGHNO KHC), Friedrich-Wilhelm-Str. 2, 53113, Bonn, Deutschland
| | - C Eich
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - C Höhne
- Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e.V. (DGAI)
- Wissenschaftlicher Arbeitskreis Kinderanästhesie (WAKKA), Nürnberg, Deutschland
| | - B A Stuck
- Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e. V. (DGHNO KHC), Friedrich-Wilhelm-Str. 2, 53113, Bonn, Deutschland
| | - A Wiater
- Kinder- und Jugendmedizin/Schlafmedizin, Deutsche Gesellschaft für Schlafforschung und Schlafmedizin (DGSM)
- Arbeitsgruppe Pädiatrie im Konvent der Deutschen Gesllschaft für Kinder- und Jugendmedizin, Schwalmstadt-Treysa, Deutschland
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9
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Nuss KE, Kunar JS, Ahrens EA. Plan-Do-Study-Act Methodology: Refining an Inpatient Pediatric Sepsis Screening Process. Pediatr Qual Saf 2020; 5:e338. [PMID: 33062902 PMCID: PMC7470006 DOI: 10.1097/pq9.0000000000000338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 07/01/2020] [Indexed: 11/26/2022] Open
Abstract
Pediatric sepsis remains a leading cause of death of children in the United States. Timely recognition and treatment are critical to prevent the onset of severe sepsis and septic shock. Electronic screening tools aid providers in identifying patients at risk for sepsis. Our overall project goal was to decrease the number of sepsis-related emergent transfers to the pediatric intensive care unit by optimizing sepsis screening tools, interruptive alerts, and a new paper tool and huddle process using Plan-Do-Study-Act (PDSA) methodology. METHODS Our team utilized historical data to develop inpatient electronic sepsis screening tools to identify pediatric patients at risk for sepsis. Using PDSA iterative cycles over 3 months, we tested the design of an interruptive alert, paper tool, and a new sepsis huddle process. RESULTS During the PDSA, the clinical teams conducted huddles on all patients who received an interruptive alert (n = 35). Eighty percent of huddles had a 5.7 minute average response time and an average duration of 5.3 minutes. Completion of the huddle outcome notes occurred 83% of the time, and 70% had feedback related to the alert, paper form, and huddle process. The number of days between sepsis-related emergent transfers to the pediatric intensive care unit increased from a median of 17.5 to 57.5 days, with a single point as high as 195 days between events. CONCLUSIONS The inpatient sepsis team learned valuable lessons using PDSA methodology. The results of the iterative cycles allowed the team to optimize and refine the tests of change. System-wide implementation benefited from the application of this quality improvement tool.
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Affiliation(s)
- Kathryn E. Nuss
- From the Department of Pediatrics, Ohio State University College of Medicine, Columbus, Ohio
- Division of Clinical Informatics, Nationwide Children’s Hospital, Columbus, Ohio
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Jillian S. Kunar
- From the Department of Pediatrics, Ohio State University College of Medicine, Columbus, Ohio
- Division of Hospital Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Erin A. Ahrens
- Information Services, Nationwide Children’s Hospital, Columbus, Ohio
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Lavin JM, Sawardekar A, Sohn L, Jones RC, Fusilero L, Iafelice ME, Molenda L. Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach. Laryngoscope 2020; 131 Suppl 1:S1-S10. [PMID: 32438522 DOI: 10.1002/lary.28760] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/16/2020] [Accepted: 04/30/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals. STUDY DESIGN Quality improvement initiative. METHODS Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU. RESULTS In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability. CONCLUSIONS Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity. LEVEL OF EVIDENCE N/A Laryngoscope, 131:S1-S10, 2021.
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Affiliation(s)
- Jennifer M Lavin
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Otolaryngology - Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Amod Sawardekar
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Lisa Sohn
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Roderick C Jones
- Department of Data Analytics and Reporting, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Laurely Fusilero
- Center for Excellence, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Mary E Iafelice
- Department of Surgical and Procedural Services, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Laura Molenda
- Department of Surgical and Procedural Services, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
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Abstract
OBJECTIVES Cardiac catheterisation is commonly used for diagnosis and therapeutic interventions in paediatric cardiology. The inherent risk of the procedure can result in unanticipated admissions to critical care. Our goals were to provide a qualitative description of characteristics and evaluation of children admitted unexpectedly to the cardiac critical care unit (CCCU). METHODS A retrospective single centre review of cardiac catheterisation procedures was done between 1 January, 2003 and 30 April, 2013. RESULTS Of 9336 cardiac catheterisations performed, 146 (1.6%) were admitted from the catheterisation laboratory to the CCCU and met inclusion criteria. Of these 146 patients, 117 (1.3%) met criteria for unexpected admission and 29 (0.3%) were planned admissions. The majority admitted unexpectedly were below 1 year of age without co-morbidity aside from heart disease. Patients with planned admissions were significantly more likely to have single ventricle physiology, undergoing angiography or transferred for observation. Most unplanned admissions were triggered by interventional catheterisations or procedure-related complications. Patients received mechanical ventilation as the main CCCU management. Eighteen patients needed either cardiopulmonary resuscitation and/or extracorporeal membrane oxygenation during their catheterisation. About 106/117 (90.6%) patients survived to hospital discharge with no deaths in the planned admission group. CONCLUSIONS Admission to CCCU following cardiac catheterisation was uncommon and tended to occur in younger children undergoing interventional procedures. Outcomes did not differ between patients experiencing planned and unplanned CCCU admission. Ongoing development of risk stratification tools may help to decrease unplanned CCCU admissions. Further studies are needed to determine whether unplanned admission following paediatric cardiac catheterisation should be utilised as a quality indicator.
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Lavin JM, Smith C, Harris ZL, Thompson DM. Critical care resources utilized in high-risk adenotonsillectomy patients. Laryngoscope 2018; 129:1229-1234. [PMID: 30582170 DOI: 10.1002/lary.27623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 09/17/2018] [Accepted: 09/24/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Children at high risk for respiratory complication after adenotonsillectomy are often admitted to a pediatric intensive care unit (PICU) postoperatively. Although many patients receive care in such units, it is unknown how many utilize critical care resources. METHODS A review was conducted to audit intensive care needs of postadenotonsillectomy patients admitted to the PICU at a tertiary, academic, pediatric hospital between July 2013, and March 2017. Demographic information, ICU indication, polysomnogram results, and comorbidities were collected. Patients were defined as needing ICU resources based on supplemental oxygen requirements greater than 2 L between 2 to 24 hours postoperatively, more than two desaturation events in a 2-hour period, or more than hourly nursing intervention. Factors associated with utilization of ICU resources were assessed. RESULTS One hundred and ten patients were admitted to the PICU after adenotonsillectomy. Median age was 4.2 years, median body mass index was 90.8 percentile, and median apnea hypopnea index (AHI) was 34.3. Twenty patients (18.2%) utilized ICU resources by criteria defined. Of these patients, 14 were known to need such resources by 2 hours postoperatively (70%, negative predictive value 93.8%). Neither AHI nor obesity status was correlated with need for resources; however, resource need was associated with young age, gastrostomy tube status, and neuromuscular disorders (P = 0.048, P = 0.002 and 0.013, respectively). CONCLUSION Most high-risk adenotonsillectomy patients do not utilize critical care resources despite their increased perioperative risk. Patients with respiratory complications are frequently identifiable within the first 2 hours of surgery. LEVEL OF EVIDENCE 4 Laryngoscope, 129:1229-1234, 2019.
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Affiliation(s)
- Jennifer M Lavin
- Division of Pediatric Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Ann and Robert H. Lurie Children's Hospital of Chicago; the Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Craig Smith
- Division of Pediatric Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Zena Leah Harris
- Division of Pediatric Critical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Dana M Thompson
- Division of Pediatric Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A.,Ann and Robert H. Lurie Children's Hospital of Chicago; the Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
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13
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Carlens J, Fuge J, Price T, DeLuca DS, Price M, Hansen G, Schwerk N. Complications and risk factors in pediatric bronchoscopy in a tertiary pediatric respiratory center. Pediatr Pulmonol 2018; 53:619-627. [PMID: 29393584 DOI: 10.1002/ppul.23957] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 01/08/2018] [Indexed: 11/09/2022]
Abstract
UNLABELLED Bronchoscopy is an established procedure routinely used by pediatric pulmonologists. Despite its frequent application, data on complications and specific risk factors are scarce and sometimes conflicting. AIM The aim of this study was to evaluate frequency and severity of clearly defined complications of bronchoscopy in children that occur both during and after the procedure, and to identify potential risk factors. METHOD A retrospective single-center analysis of 670 elective bronchoscopies in 522 children aged 0-17 years during the time period of 2008-2012 was performed. Procedures in intensive care unit patients and children after lung transplantation were excluded. RESULTS Mean patient age was 5.58 years, 61.5% had underlying chronic diseases. Intraprocedural complications occurred in 7.2% of all procedures; of these, hypoxemia was the most common, occuring in 4.8% of cases. Postprocedural adverse events were documented in 25.8%, the most frequent of which were fever in 14.2% and transient oxygen dependency in 13.4% of cases. No bronchoscopy related deaths occurred. Multivariate logistic regression was used to identify risk factors for (1) any complication, or (2) severe complications. Age below two years (OR 1.837 [1.224-2.757], P = 0.003) and primary ciliary dyskinesia (OR 4.821 [2.018-11.552], P < 0.001) significantly contributed to risk of any complication. Age below 2 years (OR 2.478 [1.072-5.728], P = 0.034) and underlying cardiovascular disease (OR 2.678 [1.013-7.077], P = 0.047) were independent risk factors for severe complications. CONCLUSION Bronchoscopy in children is relatively safe. Nevertheless, adverse events can occur and knowledge of risk factors may help prevent complications.
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Affiliation(s)
- Julia Carlens
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Jan Fuge
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease, (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Timothy Price
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - David S DeLuca
- Biomedical Research in Endstage and Obstructive Lung Disease, (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Mareike Price
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Gesine Hansen
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease, (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Nicolaus Schwerk
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease, (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
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