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Alizadeh F, Gauvreau K, Mayourian J, Brown E, Barreto JA, Blossom J, Bucholz E, Newburger JW, Kheir J, Vitali S, Thiagarajan RR, Moynihan K. Social Drivers of Health and Pediatric Extracorporeal Membrane Oxygenation Outcomes. Pediatrics 2023; 152:e2023061305. [PMID: 37933403 DOI: 10.1542/peds.2023-061305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Relationships between social drivers of health (SDoH) and pediatric health outcomes are highly complex with substantial inconsistencies in studies examining SDoH and extracorporeal membrane oxygenation (ECMO) outcomes. To add to this literature with emerging novel SDoH measures, and to address calls for institutional accountability, we examined associations between SDoH and pediatric ECMO outcomes. METHODS This single-center retrospective cohort study included children (<18 years) supported on ECMO (2012-2021). SDoH included Child Opportunity Index (COI), race, ethnicity, payer, interpreter requirement, urbanicity, and travel-time to hospital. COI is a multidimensional estimation of SDoH incorporating traditional (eg, income) and novel (eg, healthy food access) neighborhood attributes ([range 0-100] higher indicates healthier child development). Outcomes included in-hospital mortality, ECMO run duration, and length of stay (LOS). RESULTS 540 children on ECMO (96%) had a calculable COI. In-hospital mortality was 44% with median run duration of 125 hours and ICU LOS 29 days. Overall, 334 (62%) had cardiac disease, 92 (17%) neonatal respiratory failure, 93 (17%) pediatric respiratory failure, and 21 (4%) sepsis. Median COI was 64 (interquartile range 32-81), 323 (60%) had public insurance, 174 (34%) were from underrepresented racial groups, 57 (11%) required interpreters, 270 (54%) had urban residence, and median travel-time was 89 minutes. SDoH including COI were not statistically associated with outcomes in univariate or multivariate analysis. CONCLUSIONS We observed no significant difference in pediatric ECMO outcomes according to SDoH. Further research is warranted to better understand drivers of inequitable health outcomes in children, and potential protective mechanisms.
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Affiliation(s)
| | | | | | | | | | - Jeff Blossom
- Center for Geographic Analysis, Harvard University, Cambridge, Massachusetts
| | | | | | - John Kheir
- Departments of Cardiology
- Departments of Pediatrics
| | - Sally Vitali
- Anesthesia, Critical Care, Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Anesthesia, Harvard Medical School, Boston, Massachusetts
| | | | - Katie Moynihan
- Departments of Cardiology
- Departments of Pediatrics
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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2
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Mayourian J, Brown E, Javalkar K, Bucholz E, Gauvreau K, Beroukhim R, Feins E, Kheir J, Triedman J, Dionne A. Insight into the Role of the Child Opportunity Index on Surgical Outcomes in Congenital Heart Disease. J Pediatr 2023; 259:113464. [PMID: 37172810 DOI: 10.1016/j.jpeds.2023.113464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/20/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To use neighborhood-level Child Opportunity Index (COI) measures to investigate disparities in congenital heart surgery postoperative outcomes and identify potential targets for intervention. STUDY DESIGN In this single-institution retrospective cohort study, children <18 years old who underwent cardiac surgery between 2010 and 2020 were included. Patient-level demographics and neighborhood-level COI were used as predictor variables. COI-a composite US census tract-based score measuring educational, health/environmental, and social/economic opportunities-was dichotomized as lower (<40th percentile) vs higher (≥40th percentile). Cumulative incidence of hospital discharge was compared between groups using death as a competing risk, adjusting for clinical characteristics associated with outcomes. Secondary outcomes included hospital readmission and death within 30 days. RESULTS Among 6247 patients (55% male) with a median age of 0.8 years (IQR, 0.2-4.3), 26% had lower COI. Lower COI was associated with longer hospital lengths of stay (adjusted HR, 1.2; 95% CI, 1.1-1.2; P < .001) and an increased risk of death (adjusted OR, 2.0; 95% CI. 1.4-2.8; P < .001), but not hospital readmission (P = .6). At the neighborhood level, lacking health insurance coverage, food/housing insecurity, lower parental literacy and college attainment, and lower socioeconomic status were associated with longer hospital length of stay and increased risk of death. At the patient-level, public insurance (adjusted OR, 1.4; 95% CI, 1.0-2.0; P = .03) and caretaker Spanish language (adjusted OR 2.4; 95% CI, 1.2-4.3; P < .01) were associated with an increased risk of death. CONCLUSIONS Lower COI is associated with longer length of stay and higher early postoperative mortality. Risk factors identified including Spanish language, food/housing insecurity, and parental literacy serve as potential intervention targets.
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Affiliation(s)
- Joshua Mayourian
- Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Pediatrics, Boston University, Boston, MA
| | - Ella Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Karina Javalkar
- Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Pediatrics, Boston University, Boston, MA
| | - Emily Bucholz
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kimberlee Gauvreau
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Rebecca Beroukhim
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Eric Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - John Kheir
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - John Triedman
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Audrey Dionne
- Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Cardiology, Boston Children's Hospital, Boston, MA.
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3
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Meziab O, Feins E, Kheir J, Delgado M, Godsay M, O'Leary E, Triedman JK, Walsh EP, Dionne A. B-PO03-199 SINUS NODE DYSFUNCTION AFTER SURGERY FOR CONGENITAL HEART DISEASE: INCIDENCE AND IMPACT ON RECOVERY. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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4
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Dasgupta S, Shalhoub K, El-Assaad I, Manasee Godsay MD, O'Leary E, Feins E, Triedman JK, Walsh EP, Kheir J, Dionne A. B-PO02-198 PREDICTING POST-OPERATIVE ACCELERATED JUNCTIONAL RHYTHM AND JUNCTIONAL ECTOPIC TACHYCARDIA: OPPORTUNITY FOR PREVENTION? Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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El-Assaad I, Hood-Pishchany MI, Kheir J, Mistry K, Dixit A, Halyabar O, Mah DY, Meyer-Macaulay C, Cheng H. Complete Heart Block, Severe Ventricular Dysfunction, and Myocardial Inflammation in a Child With COVID-19 Infection. JACC Case Rep 2020; 2:1351-1355. [PMID: 32835278 PMCID: PMC7237189 DOI: 10.1016/j.jaccas.2020.05.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 12/16/2022]
Abstract
A young child presented with severe ventricular dysfunction and troponin leak in the setting of coronavirus disease-2019. He developed intermittent, self-resolving, and hemodynamically insignificant episodes of complete heart block that were diagnosed on telemetry and managed conservatively. This report is the first description of coronavirus disease-2019-induced transient complete heart block in a child. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Iqbal El-Assaad
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - M. Indriati Hood-Pishchany
- Division of Infectious Disease, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - John Kheir
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Kshitij Mistry
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Avika Dixit
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Olha Halyabar
- Rheumatology Program, Division of Immunology, Boston Children’s Hospital, Boston, Massachusetts
| | - Douglas Y. Mah
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Henry Cheng
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
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6
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Assaad IE, Hood-Pishchany MI, Kheir J, Mistry K, Dixit A, Halyabar O, Mah DY, Meyer-Macaulay C, Cheng H. WITHDRAWN: Complete Heart Block, Severe Ventricular Dysfunction and Myocardial Inflammation in a Child with COVID-19 Infection. JACC Case Rep 2020:S2666-0849(20)30585-4. [PMID: 32838330 PMCID: PMC7250756 DOI: 10.1016/j.jaccas.2020.05.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 11/22/2022]
Abstract
The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.jaccas.2020.05.023>. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
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Affiliation(s)
- Iqbal El Assaad
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - M Indriati Hood-Pishchany
- Division of Infectious Disease, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - John Kheir
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Kshitij Mistry
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Avika Dixit
- Division of Infectious Disease, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Olha Halyabar
- Rheumatology Program, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Henry Cheng
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
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7
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Mille FK, Badheka A, Yu P, Zhang X, Friedman DF, Kheir J, van den Bosch S, Cabrera AG, Lasa JJ, Katcoff H, Hu P, Borasino S, Hock K, Huskey J, Weller J, Kothari H, Blinder J. Red Blood Cell Transfusion After Stage I Palliation Is Associated With Worse Clinical Outcomes. J Am Heart Assoc 2020; 9:e015304. [PMID: 32390527 PMCID: PMC7660859 DOI: 10.1161/jaha.119.015304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/27/2020] [Indexed: 12/13/2022]
Abstract
Background Packed red blood cell transfusion may improve oxygen content in single-ventricle neonates, but its effect on clinical outcomes after Stage 1 palliation is unknown. Methods and Results Retrospective multicenter analysis of packed red blood cell transfusion exposures in neonates after Stage 1 palliation, excluding those with intraoperative mortality or need for extracorporeal membrane oxygenation. Transfusion practice variability was assessed, and multivariable regression used to identify transfusion risk factors. After propensity score adjustment for severity of illness, clinical outcomes were compared between transfused and nontransfused subjects. Of 396 subjects, 323 (82%) received 930 postoperative red blood cell transfusions. Packed red blood cell volume (median 9-42 mL/kg [P<0.0001]), donor exposures (1-2 [P<0.0001]), transfusion number (1-3 [P<0.0001]), and pretransfusion hemoglobin (12.1-13 g/dL, P=0.0049) varied between sites. Cyanosis (P=0.02), chest tube output (P=0.0003), and delayed sternal closure (P=0.0033) increased transfusion risk. Transfusion was associated with prolonged mechanical ventilation (6 [interquartile range 4, 12] versus 3 [1, 5] days, P=0.02) and intensive care unit stay (19 [12, 33] versus 9 [6, 19] days, P=0.016). When stratified by number of transfusions (0, 1, or >1), duration of mechanical ventilation (3 [1, 5] versus 4 [3, 6] versus 9 [5, 16] days [P<0.0001]) and intensive care unit stay (9 [6, 19] versus 13 [8, 25] versus 21 [13, 38] days [P<0.0001]) increased for those transfused more than once. Most subjects who died were transfused, though the association with mortality was not significant. Conclusions Packed red blood cell transfusion after Stage 1 palliation is common, and transfusion practice is variable. Transfusion is a significant predictor of longer intensive care unit stay and mechanical ventilation. Further studies to define evidence-based transfusion thresholds are warranted.
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Affiliation(s)
| | - Aditya Badheka
- University of Iowa Stead Family Children’s HospitalIowa CityIA
| | - Priscilla Yu
- University of Texas Southwestern Medical CenterDallasTX
| | - Xuemei Zhang
- The Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | | | | | | | | | | | | | - Paula Hu
- The Children’s Hospital of PhiladelphiaPhiladelphiaPA
| | | | | | | | - Jamie Weller
- University of Texas Southwestern Medical CenterDallasTX
| | - Harsh Kothari
- University of Iowa Stead Family Children’s HospitalIowa CityIA
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8
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Dionne A, Kheir J, Sleeper L, Esch J, Breitbart R. VALUE OF TROPONIN TESTING FOR DETECTION OF HEART DISEASE IN PREVIOUSLY HEALTHY CHILDREN. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31245-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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9
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Ahmed H, Tang X, Polizzotti B, Gauvreau K, Kellogg M, DiNardo J, Kheir J. Use of Oxyhemoglobin Saturation, Rather Than Oxygen Tension, as a Marker of Oxygenation in Cyanotic Patients. JAMA Pediatr 2017; 171:1012-1014. [PMID: 28828474 PMCID: PMC6583377 DOI: 10.1001/jamapediatrics.2017.2213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study analyzes clinically indicated arterial blood gas values from patients with cyanotic congenital heart disease to determine whether oxyhemoglobin saturation or arterial oxygen tension provides a better measure of oxygenation.
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Affiliation(s)
- Humera Ahmed
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Xiaoqi Tang
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Brian Polizzotti
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Mark Kellogg
- Department of Laboratory Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - James DiNardo
- Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts,Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - John Kheir
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Abstract
A detailed study is presented on the synthesis and characterization of purely oxygen-filled microbubbles (OMBs) stabilized by phospholipids. Microbubbles with a diameter of less than 10 μm were generated and concentrated to >50 vol % in saline. The lipid acyl chain length had little effect on the size distribution but profoundly affected the foam stability. For example, OMBs stabilized by dipalmitoyl phosphatidylcholine (DPPC) degraded over 3 weeks, but OMBs stabilized with distearoyl phosphatidylcholine (DSPC) retained over half of their initially encapsulated gas. Interestingly, the polydisperse size distribution remained nearly constant as the foam slowly broke down. Injection into an undersaturated solution led to the immediate release of the oxygen gas core. Injectable gas delivery by OMBs may find use in a variety of medical and industrial fields.
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Affiliation(s)
- Edward J Swanson
- Department of Chemical Engineering, Columbia University, New York, New York 10027, USA
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Brilli RJ, Gibson R, Luria JW, Wheeler TA, Shaw J, Linam M, Kheir J, McLain P, Lingsch T, Hall-Haering A, McBride M. Implementation of a medical emergency team in a large pediatric teaching hospital prevents respiratory and cardiopulmonary arrests outside the intensive care unit. Pediatr Crit Care Med 2007; 8:236-46; quiz 247. [PMID: 17417113 DOI: 10.1097/01.pcc.0000262947.72442.ea] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We implemented a medical emergency team (MET) in our free-standing children's hospital. The specific aim was to reduce the rate of codes (respiratory and cardiopulmonary arrests) outside the intensive care units by 50% for >6 months following MET implementation. DESIGN Retrospective chart review and program implementation. SETTING A children's hospital. PATIENTS None. INTERVENTIONS The records of patients who required cardiorespiratory resuscitation outside the critical care areas were reviewed before MET implementation to determine activation criteria for the MET. Codes were prospectively defined as respiratory arrests or cardiopulmonary arrests. MET-preventable codes were prospectively defined. The incidence of codes before and after MET implementation was recorded. MEASUREMENTS AND MAIN RESULTS Twenty-five codes occurred during the pre-MET baseline compared with six following MET implementation. The code rate (respiratory arrests + cardiopulmonary arrests) post-MET was 0.11 per 1,000 patient days compared with baseline of 0.27 (risk ratio, 0.42; 95% confidence interval, 0-0.89; p = .03). The code rate per 1,000 admissions decreased from 1.54 (baseline) to 0.62 (post-MET) (risk ratio, 0.41; 95% confidence interval, 0-0.86; p = .02). For MET-preventable codes, the code rate post-MET was 0.04 per 1,000 patient days compared with a baseline of 0.14 (risk ratio, 0.27; 95% confidence interval, 0-0.94; p = .04). There was no difference in the incidence of cardiopulmonary arrests before and after MET. For codes outside the intensive care unit, the pre-MET mortality rate was 0.12 per 1,000 days compared with 0.06 post-MET (risk ratio, 0.48; 95% confidence interval, 0-1.4, p = .13). The overall mortality rate for outside the intensive care unit codes was 42% (15 of 36 patients). CONCLUSIONS Implementation of a MET is associated with a reduction in the risk of respiratory and cardiopulmonary arrest outside of critical care areas in a large tertiary children's hospital.
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Affiliation(s)
- Richard J Brilli
- Pediatric Intensive Care Unit, Cincinnati College of Medicine, Cincinnati, OH, USA.
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Abstract
The Quick Confusion Scale (QCS) is a 6-item battery of questions focusing on orientation, memory, and concentration weighted to yield a top score of 15. Analysis of the QCS compared with the Mini-Mental State Examination (MMSE) is needed to determine if the QCS is a valid marker of cognitive mental status. The MMSE and the QCS were administered to a convenience sample of 205 patients presenting to the emergency department. Exclusions included head trauma, multisystem trauma, Glasgow Coma Scale less than 15, non-English speaking, education level less than 8 years, contact or droplet isolation, acute illness, or incomplete data for reasons such as restricted patient access. Mean scores were 24.8(SD = 4.7; range 2-30) on the MMSE and 11.89 (SD = 3.5; range 0-15) on the QCS. QCS scores were significantly correlated (r = .783) with MMSE scores. The QCS appears comparable with the MMSE and is quicker to administer.
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Affiliation(s)
- J S Huff
- Department of Emergency Medicine, University of Virginia Health Sciences Center, Charlottesville 22908-0699, USA.
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