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Furthmiller A, Sahay R, Zhang B, Dewan M, Zackoff M. Impact of a relocation to a new critical care building on pediatric safety events. J Hosp Med 2024. [PMID: 38433358 DOI: 10.1002/jhm.13324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/07/2024] [Accepted: 02/16/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Cincinnati Children's Hospital Medical Center (CCHMC) relocated the pediatric, cardiac, and neonatal intensive care units (PICU, CICU and NICU) to a newly constructed critical care building (CCB) in November 2021. Simulation and onboarding sessions were implemented before the relocation, aimed at mitigating latent safety threats. OBJECTIVE To evaluate the impact of ICU relocation to the CCHMC CCB on patient safety as measured by the quantity, rate, severity score, and category of safety reports. METHODS This retrospective, cross-sectional, observational study compared safety reports filed in a 90-day period before and following the CCB relocation. The primary outcome was pre- and postrelocation safety report rates per 100 patient-days. Secondary outcomes included safety report severity, category, and rate of hospital acquired conditions (HACs). RESULTS Total safety report incidence increased by 16% across all ICUs postrelocation with no difference in post- versus prerelocation odds ratio between ICUs. Three isolated instances of special cause variation were found, one in NICU and two in CICU. No special cause variation was found in the PICU. There were no statistical differences in assigned safety report severity pre- to postrelocation for all ICUs, and only lab specimen/test related safety reports showed a statistically significant increase postrelocation. Overall rates of HACs were low, with six occurring prerelocation and eight postrelocation. CONCLUSIONS All three ICUs were relocated to the new CCB with minimal changes in the incidence, severity, or category of safety reports filed, suggesting staff training and preparations ahead of the relocation mitigated latent safety threats.
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Affiliation(s)
- Andrew Furthmiller
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rashmi Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Matthew Zackoff
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Center for Simulation Research, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Molloy MJ, Zackoff M, Gifford A, Hagedorn P, Tegtmeyer K, Britto MT, Dewan M. Usability Testing of Situation Awareness Clinical Decision Support in the Intensive Care Unit. Appl Clin Inform 2024; 15:327-334. [PMID: 38378044 PMCID: PMC11062760 DOI: 10.1055/a-2272-6184] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/18/2024] [Indexed: 02/22/2024] Open
Abstract
OBJECTIVE Our objective was to evaluate the usability of an automated clinical decision support (CDS) tool previously implemented in the pediatric intensive care unit (PICU) to promote shared situation awareness among the medical team to prevent serious safety events within children's hospitals. METHODS We conducted a mixed-methods usability evaluation of a CDS tool in a PICU at a large, urban, quaternary, free-standing children's hospital in the Midwest. Quantitative assessment was done using the system usability scale (SUS), while qualitative assessment involved think-aloud usability testing. The SUS was scored according to survey guidelines. For think-aloud testing, task times were calculated, and means and standard deviations were determined, stratified by role. Qualitative feedback from participants and moderator observations were summarized. RESULTS Fifty-one PICU staff members, including physicians, advanced practice providers, nurses, and respiratory therapists, completed the SUS, while ten participants underwent think-aloud usability testing. The overall median usability score was 87.5 (interquartile range: 80-95), with over 96% rating the tool's usability as "good" or "excellent." Task completion times ranged from 2 to 92 seconds, with the quickest completion for reviewing high-risk criteria and the slowest for adding to high-risk criteria. Observations and participant responses from think-aloud testing highlighted positive aspects of learnability and clear display of complex information that is easily accessed, as well as opportunities for improvement in tool integration into clinical workflows. CONCLUSION The PICU Warning Tool demonstrates good usability in the critical care setting. This study demonstrates the value of postimplementation usability testing in identifying opportunities for continued improvement of CDS tools.
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Affiliation(s)
- Matthew J. Molloy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Hospital Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
- Division of Biomedical Informatics, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
| | - Matthew Zackoff
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Critical Care, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
| | | | - Philip Hagedorn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Hospital Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
- Division of Biomedical Informatics, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Critical Care, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
| | - Maria T. Britto
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Biomedical Informatics, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
- Division of Critical Care, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, Ohio, United States
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O'Halloran A, Lockwood J, Sosa T, Gawronski O, Nadkarni V, Kleinman M, Dewan M. How do we detect and respond to clinical deterioration in hospitalized children? Results of the Pediatric Care BefOre Deterioration Events (CODE) survey. J Hosp Med 2023; 18:1102-1108. [PMID: 37861210 DOI: 10.1002/jhm.13224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/27/2023] [Accepted: 09/29/2023] [Indexed: 10/21/2023]
Abstract
Systems to detect and respond to deteriorating hospitalized children are common despite little evidence supporting best practices. Our objective was to describe systems to detect/respond to deteriorating hospitalized children at Pediatric Resuscitation Quality Collaborative (pediRES-Q) institutions. We performed a cross-sectional survey of pediRES-Q leaders. Questionnaire design utilized expert validation and cognitive interviews. Thirty centers (88%) responded. Most (93%) used ≥1 system to detect deterioration: most commonly, early warning scores (83%), watcher lists (55%), and proactive surveillance teams (31%). Most (90%) had a team to respond to deteriorating patients and the majority of teams could be activated by clinician or family concerns. Most institutions (90%) collect relevant data, including number of rapid responses (88%), arrests outside intensive care units (100%), and serious safety events (88%). In conclusion, most pediRES-Q institutions utilize systems to detect/respond to deteriorating hospitalized children. Heterogeneity exists among programs. Rigorous evaluation is needed to identify best practices.
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Affiliation(s)
- Amanda O'Halloran
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Justin Lockwood
- Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tina Sosa
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
- Division of Pediatric Hospital Medicine, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Quality Institute, Rochester, New York, USA
| | - Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Vinay Nadkarni
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Monica Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts, USA
| | - Maya Dewan
- Division of Critical Care, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
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Myers C, Tegtmeyer K, Dewan M. Championing the Spirit of O'hana in the PICU. Pediatr Crit Care Med 2023; 24:1092-1093. [PMID: 38055004 DOI: 10.1097/pcc.0000000000003367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Affiliation(s)
- Carlie Myers
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Ken Tegtmeyer
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Maya Dewan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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5
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Gifford A, Butcher B, Chima RS, Moore L, Brady PW, Zackoff MW, Dewan M. Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit. J Hosp Med 2023; 18:978-985. [PMID: 37792360 DOI: 10.1002/jhm.13216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/11/2023] [Accepted: 09/16/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Optimal design of healthcare spaces can enhance patient care. We applied design thinking and human factors principles to optimize communication and signage on high risk patients to improve situation awareness in a new clinical space for the pediatric ICU. OBJECTIVE To assess the impact of these tools in mitigating situation awareness concerns within the new clinical space. We hypothesized that implementing these design-informed tools would either maintain or improve situation awareness. DESIGN, SETTINGS, AND PARTICIPANTS A 15-week design thinking process was employed, involving research, ideation, and refinement to develop and implement new situation awareness tools. The process included engagement with interprofessional clinical teams, scenario planning, workflow mapping, iterative feedback collection, and collaboration with an industry partner for signage development and implementation. INTERVENTION Improved and updated communication devices and bedside mitigation plans. MAIN OUTCOME AND MEASURES Process metrics included individual and shared situation awareness of PICU care teams and our patient outcome metric was the rate of cardiopulmonary resuscitation (CPR) events pre- and post-transition. RESULTS When evaluating all patients, shared situation awareness for accurate high-risk status improved from 81% pre-transition to 92% post-transition (p = .006). When assessing individual care team roles, accuracy of patient high-risk status improved from 88% to 95% (p = .05) for RNs, 85% to 96% (p = .003) for residents, and 88% to 95% (p = .03) for RTs. There was no change in the rate of CPR events following the transition.
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Affiliation(s)
| | - Bain Butcher
- College of Design, Art, Architecture, and Planning, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ranjit S Chima
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lindsey Moore
- Pediatric Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Patrick W Brady
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Matthew W Zackoff
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Maya Dewan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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6
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Woods-Hill CZ, Wolfe H, Malone S, Steffen KM, Agulnik A, Flaherty BF, Barbaro RP, Dewan M, Kudchadkar S. Implementation Science Research in Pediatric Critical Care Medicine. Pediatr Crit Care Med 2023; 24:943-951. [PMID: 37916878 PMCID: PMC10624111 DOI: 10.1097/pcc.0000000000003335] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Delay or failure to consistently adopt evidence-based or consensus-based best practices into routine clinical care is common, including for patients in the PICU. PICU patients can fail to receive potentially beneficial diagnostic or therapeutic interventions, worsening the burden of illness and injury during critical illness. Implementation science (IS) has emerged to systematically address this problem, but its use of in the PICU has been limited to date. We therefore present a conceptual and methodologic overview of IS for the pediatric intensivist. DESIGN The members of Excellence in Pediatric Implementation Science (ECLIPSE; part of the Pediatric Acute Lung Injury and Sepsis Investigators Network) represent multi-institutional expertise in the use of IS in the PICU. This narrative review reflects the collective knowledge and perspective of the ECLIPSE group about why IS can benefit PICU patients, how to distinguish IS from quality improvement (QI), and how to evaluate an IS article. RESULTS IS requires a shift in one's thinking, away from questions and outcomes that define traditional clinical or translational research, including QI. Instead, in the IS rather than the QI literature, the terminology, definitions, and language differs by specifically focusing on relative importance of generalizable knowledge, as well as aspects of study design, scale, and timeframe over which the investigations occur. CONCLUSIONS Research in pediatric critical care practice must acknowledge the limitations and potential for patient harm that may result from a failure to implement evidence-based or professionals' consensus-based practices. IS represents an innovative, pragmatic, and increasingly popular approach that our field must readily embrace in order to improve our ability to care for critically ill children.
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Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Heather Wolfe
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Sara Malone
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine
| | - Katherine M Steffen
- Stanford University Department of Pediatrics, Division of Pediatric Critical Care Medicine
| | - Asya Agulnik
- Department of Global Pediatric Medicine, Division of Critical Care, St Jude Children’s Research Hospital
| | - Brian F Flaherty
- University of Utah, Department of Pediatrics, Division of Critical Care
| | - Ryan P Barbaro
- Division of Pediatric Critical Care, University of Michigan Medical School, Ann Arbor, MI; Susan B. Miester Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine; Cincinnati, OH; Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center; Cincinnati, OH; Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center; Cincinnati, OH
| | - Sapna Kudchadkar
- Department of Anesthesiology and Critical Care Medicine; Department of Pediatrics; Department of Physical Medicine & Rehabilitation. Johns Hopkins University School of Medicine, Baltimore, Maryland
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7
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Galligan MM, Sosa T, Dewan M. The Need for a Standard Outcome for Clinical Deterioration in Children's Hospitals. Pediatrics 2023; 152:e2023061625. [PMID: 37701963 DOI: 10.1542/peds.2023-061625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 09/14/2023] Open
Abstract
Unrecognized clinical deterioration is a common and significant source of preventable harm to hospitalized children. Yet, unlike other sources of preventable harm, clinical deterioration outside of the ICU lacks a clear, "gold standard" outcome to guide prevention efforts. This gap limits multicenter learning, which is crucial for identifying effective and generalizable interventions for harm prevention. In fact, to date, no coordinated safety/quality initiative currently exists targeting prevention of harm from unrecognized clinical deterioration in hospitalized pediatric patients, which is startling given the morbidity and mortality risk patients incur. In this article, we compare existing outcomes for evaluating clinical deterioration outside of the ICU, highlighting sources of variation and vulnerability. The broader aim of this article is to highlight the need for a standard, consensus outcome for evaluating clinical deterioration outside of the ICU, which is a critical first step to preventing this type of harm.
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Affiliation(s)
- Meghan M Galligan
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Division of General Pediatrics, and
- Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tina Sosa
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York
- Division of Pediatric Hospital Medicine, Golisano Children's Hospital
- UR Medicine Quality Institute, University of Rochester Medical Center, Rochester, New York
| | - Maya Dewan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Divisions of Critical Care Medicine, and
- Biomedical Informatics
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Gray JM, Raymond TT, Atkins DL, Tegtmeyer K, Niles DE, Nadkarni VM, Pandit SV, Dewan M. Inappropriate Shock Delivery Is Common During Pediatric In-Hospital Cardiac Arrest. Pediatr Crit Care Med 2023; 24:e390-e396. [PMID: 37115167 PMCID: PMC10440232 DOI: 10.1097/pcc.0000000000003241] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVES To characterize inappropriate shock delivery during pediatric in-hospital cardiac arrest (IHCA). DESIGN Retrospective cohort study. SETTING An international pediatric cardiac arrest quality improvement collaborative Pediatric Resuscitation Quality [pediRES-Q]. PATIENTS All IHCA events from 2015 to 2020 from the pediRES-Q Collaborative for which shock and electrocardiogram waveform data were available. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed 418 shocks delivered during 159 cardiac arrest events, with 381 shocks during 158 events at 28 sites remaining after excluding undecipherable rhythms. We classified shocks as: 1) appropriate (ventricular fibrillation [VF] or wide complex ≥ 150/min); 2) indeterminate (narrow complex ≥ 150/min or wide complex 100-149/min); or 3) inappropriate (asystole, sinus, narrow complex < 150/min, or wide complex < 100/min) based on the rhythm immediately preceding shock delivery. Of delivered shocks, 57% were delivered appropriately for VF or wide complex rhythms with a rate greater than or equal to 150/min. Thirteen percent were classified as indeterminate. Thirty percent were delivered inappropriately for asystole (6.8%), sinus (3.1%), narrow complex less than 150/min (11%), or wide complex less than 100/min (8.9%) rhythms. Eighty-eight percent of all shocks were delivered in ICUs or emergency departments, and 30% of those were delivered inappropriately. CONCLUSIONS The rate of inappropriate shock delivery for pediatric IHCA in this international cohort is at least 30%, with 23% delivered to an organized electrical rhythm, identifying opportunity for improvement in rhythm identification training.
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Affiliation(s)
- James M. Gray
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | - Dianne L. Atkins
- Division of Cardiology, Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Division of Critical Care, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Dana E. Niles
- Department of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Vinay M. Nadkarni
- Department of Anesthesia and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Maya Dewan
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
- Division of Cardiology, Department of Pediatrics, University of Iowa, Iowa City, IA
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Frazier M, Webster K, Dewan M, Hutson T, Collins K, Fettig T, Grooms T, Cordray M, Tegtmeyer K. Improving Usability of the Pediatric Code Cart by Combining Lean and Human Factors Principles. Pediatr Qual Saf 2023; 8:e676. [PMID: 37551262 PMCID: PMC10402944 DOI: 10.1097/pq9.0000000000000676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 06/22/2023] [Indexed: 08/09/2023] Open
Abstract
Cardiac arrests are common in hospitalized children. Well-organized code carts are needed during these events to help staff efficiently find supplies and medications for the patient. This study aimed to improve the efficiency and utilization of the code cart at a major academic pediatric medical center. Methods This quality improvement project used a phased approach to redesign the code cart. A multidisciplinary team used Lean and Human Factors principles to improve the efficiency and intuitiveness of the redesigned cart. Nurses and respiratory therapists participated in simulations asking for certain supplies with the original and redesigned code cart and filled out surveys for feedback on each code cart. Facilitators measured retrieval times during each simulation. Results We performed 10 simulations with the original code cart and 13 with the redesigned code cart. Staff could find intraosseous access equipment more quickly (23.9 versus 46.4 seconds; P = 0.003). In addition, staff reported they were less likely to open the wrong drawer or grab the wrong equipment and that the redesigned code cart was overall more well organized than the original code cart. Finally, the redesigned code cart reduced the cost by over 800 dollars per full cart restock. Conclusion Revising the code cart using Lean and Human Factors improves efficiency and usability and can contribute to cost savings.
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Affiliation(s)
- Maria Frazier
- From the Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kristen Webster
- Patient Safety, Regulatory, and Accreditation, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Maya Dewan
- From the Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Tamara Hutson
- Division of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kelly Collins
- From the Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Tina Fettig
- From the Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Taylor Grooms
- Department of Pediatrics, Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Ken Tegtmeyer
- From the Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Brown SR, Frazier M, Roberts J, Wolfe H, Tegtmeyer K, Sutton R, Dewan M. CPR Quality and Outcomes After Extracorporeal Life Support for Pediatric In-Hospital Cardiac Arrest. Resuscitation 2023:109874. [PMID: 37327853 DOI: 10.1016/j.resuscitation.2023.109874] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/19/2023] [Accepted: 05/28/2023] [Indexed: 06/18/2023]
Abstract
AIM of Study: To determine outcomes in pediatric patients who had an in-hospital cardiac arrest and subsequently received extracorporeal cardiopulmonary resuscitation (ECPR). Our secondary objective was to identify cardiopulmonary resuscitation (CPR) event characteristics and CPR quality metrics associated with survival after ECPR. METHODS Multicenter retrospective cohort study of pediatric patients in the pediRES-Q database who received ECPR after in-hospital cardiac arrest between July 1, 2015 and June 2, 2021. Primary outcome was survival to ICU discharge. Secondary outcomes were survival to hospital discharge and favorable neurologic outcome at ICU and hospital discharge. RESULTS Among 124 patients included in this study, median age was 0.9 years (IQR 0.2-5) and the majority of patients had primarily cardiac disease (92 patients, 75%). Survival to ICU discharge occurred in 61/120 (51%) patients, 36/61 (59%) of whom had favorable neurologic outcome. No demographic or clinical variables were associated with survival after ECPR. CONCLUSION In this multicenter retrospective cohort study of pediatric patients who received ECPR for IHCA we found a high rate of survival to ICU discharge with good neurologic outcome.
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Affiliation(s)
- Stephanie R Brown
- Section of Pediatric Critical Care Medicine, Oklahoma Children's Hospital, Oklahoma City, OK, USA; Division of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Maria Frazier
- Division of Pediatric Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joan Roberts
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Heather Wolfe
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ken Tegtmeyer
- Division of Pediatric Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Robert Sutton
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maya Dewan
- Division of Pediatric Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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11
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Dewan M, Tegtmeyer K, Stalets EL. Through the Looking-Glass Door. Pediatr Crit Care Med 2023; 24:425-426. [PMID: 37140334 DOI: 10.1097/pcc.0000000000003227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Maya Dewan
- All authors: Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Banerjee S, Leary A, Stewart J, Dewan M, Lheureux S, Clamp A, Ray-Coquard I, Selle F, Gourley C, Glasspool R, Bowen R, Attygalle A, Vroobel K, Tunariu N, Wilkinson K, Toms C, Natrajan R, Bliss J, Lord C, Porta N. 34O ATR inhibitor alone (ceralasertib) or in combination with olaparib in gynaecological cancers with ARID1A loss or no loss: Results from the ENGOT/GYN1/NCRI ATARI trial. ESMO Open 2023. [DOI: 10.1016/j.esmoop.2023.100814] [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] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
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13
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Alten J, Cooper DS, Klugman D, Raymond TT, Wooton S, Garza J, Clarke-Myers K, Anderson J, Pasquali SK, Absi M, Affolter JT, Bailly DK, Bertrandt RA, Borasino S, Dewan M, Domnina Y, Lane J, McCammond AN, Mueller DM, Olive MK, Ortmann L, Prodhan P, Sasaki J, Scahill C, Schroeder LW, Werho DK, Zaccagni H, Zhang W, Banerjee M, Gaies M. Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration. JAMA Pediatr 2022; 176:1027-1036. [PMID: 35788631 PMCID: PMC9257678 DOI: 10.1001/jamapediatrics.2022.2238] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/28/2022] [Indexed: 12/14/2022]
Abstract
Importance Preventing in-hospital cardiac arrest (IHCA) likely represents an effective strategy to improve outcomes for critically ill patients, but feasibility of IHCA prevention remains unclear. Objective To determine whether a low-technology cardiac arrest prevention (CAP) practice bundle decreases IHCA rate. Design, Setting, and Participants Pediatric cardiac intensive care unit (CICU) teams from the Pediatric Cardiac Critical Care Consortium (PC4) formed a collaborative learning network to implement the CAP bundle consistent with the Institute for Healthcare Improvement framework; 15 hospitals implemented the bundle voluntarily. Risk-adjusted IHCA incidence rates were analyzed across 2 time periods, 12 months (baseline) and 18 months after CAP implementation (intervention) using difference-in-differences (DID) regression to compare 15 CAP and 16 control PC4 hospitals that chose not to participate in CAP but had IHCA rates tracked in the PC4 registry. Patients deemed at high risk for IHCA, based on a priori evidence-based criteria and empirical hospital-specific criteria, were selected to receive the CAP bundle. Data were collected from July 2018 to December 2019, and data were analyzed from March to August 2020. Interventions CAP bundle included 5 elements developed to promote increased situational awareness and communication among bedside clinicians to recognize and mitigate deterioration in high-risk patients. Main Outcomes and Measures Risk-adjusted IHCA incidence rate across all CICU admissions (IHCA events divided by all admissions). Results The bundle was activated in 2664 of 10 510 CAP hospital admissions (25.3%); admission characteristics were similar across study periods. There was a 30% relative reduction in risk-adjusted IHCA incidence rate at CAP hospitals (intervention period: 2.6%; 95% CI, 2.2-2.9; baseline: 3.7%; 95% CI, 3.1-4.0), but no change at control hospitals (intervention period: 2.7%; 95% CI, 2.3-2.9; baseline: 2.7%; 95% CI, 2.2-3.0). DID analysis confirmed significantly reduced odds of IHCA among all admissions at CAP hospitals compared with control hospitals during the intervention period vs baseline (odds ratio, 0.72; 95% CI, 0.56-0.91; P = .01). DID odds ratios were 0.72 (95% CI, 0.53-0.98) for the surgical subgroup, 0.74 (95% CI, 0.48-1.14) for the medical subgroup, and 0.72 (95% CI, 0.50-1.03) for the high-risk admission subgroup at CAP hospitals after intervention. All-cause risk-adjusted mortality rate did not change after intervention. Conclusions and Relevance Implementation of this CAP bundle led to significant IHCA reduction across multiple pediatric CICUs. Future studies may determine if this bundle can be effective in other critically ill populations.
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Affiliation(s)
- Jeffrey Alten
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - David S. Cooper
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Darren Klugman
- Division of Cardiac Critical Care Medicine, Children’s National Hospital, Washington, DC
- Division of Anesthesia, Critical Care Medicine, Johns Hopkins Children’s Center, Baltimore, Maryland
| | - Tia Tortoriello Raymond
- Department of Pediatrics, Cardiac Critical Care, Medical City Children’s Hospital, Dallas, Texas
| | - Sharyl Wooton
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Janie Garza
- Department of Pediatrics, Cardiac Critical Care, Medical City Children’s Hospital, Dallas, Texas
| | - Katherine Clarke-Myers
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Jeffrey Anderson
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Sara K. Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, C.S. Mott Children’s Hospital, Ann Arbor
| | - Mohammed Absi
- Department of Pediatrics, Heart Institute, University of Tennessee, Le Bonheur Children’s Hospital, Memphis
| | - Jeremy T. Affolter
- Department of Pediatrics, Critical Care Medicine, University of Missouri, Children’s Mercy Hospital, Kansas City
- Department of Pediatrics, University of Texas at Austin-Dell Medical School, Dell Children’s Medical Center of Central Texas, Austin
| | - David K. Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City
| | - Rebecca A. Bertrandt
- Department of Pediatric Critical Care, Medical College of Wisconsin, Children’s Wisconsin, Milwaukee
| | - Santiago Borasino
- Department of Pediatrics, University of Alabama at Birmingham, Cardiac Critical Care, Birmingham
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati School of Medicine, Division of Critical Care Medicine, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Yuliya Domnina
- Division of Cardiac Critical Care Medicine, Children’s National Hospital, Washington, DC
- Department of Pediatrics and Critical Care Medicine, Cardiac Intensive Care Unit, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John Lane
- Division of Cardiovascular Intensive Care, Phoenix Children’s Hospital, Phoenix Arizona
| | - Amy N. McCammond
- Department of Pediatrics, Pediatric Cardiac Intensive Care, University of California San Francisco, Benioff Children’s Hospital, San Francisco
| | - Dana M. Mueller
- Department of Pediatrics, Division of Critical Care, University of Washington, Seattle Children’s Hospital, Seattle
- Division of Cardiology, Department of Pediatrics, University of California San Diego, Rady Children’s Hospital, San Diego
| | - Mary K. Olive
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, C.S. Mott Children’s Hospital, Ann Arbor
| | - Laura Ortmann
- Department of Pediatrics, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha
| | - Parthak Prodhan
- Division of Pediatric Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock
| | - Jun Sasaki
- Division of Cardiac Critical Care Medicine, Nicklaus Children’s Hospital, Miami, Florida
- Division of Critical Care Medicine, Department of Pediatrics, Weill Cornell Medicine, New York, New York
| | - Carly Scahill
- Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, Aurora
| | - Luke W. Schroeder
- Department of Pediatrics, Medical University of South Carolina, Charleston
| | - David K. Werho
- Division of Cardiology, Department of Pediatrics, University of California San Diego, Rady Children’s Hospital, San Diego
| | - Hayden Zaccagni
- Department of Pediatrics, University of Alabama at Birmingham, Cardiac Critical Care, Birmingham
| | - Wenying Zhang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Mousumi Banerjee
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Michael Gaies
- Department of Pediatrics, University of Cincinnati School of Medicine, Heart Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
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14
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Kienzle MF, Morgan RW, Dewan M, Hebbar KB, Nadkarni VM, Srinivasan V, Tegtmeyer K, Sutton RM, Wolfe HA. Weight-Based Versus Flat Dosing of Epinephrine During Cardiac Arrest in the PICU: A Multicenter Survey. Pediatr Crit Care Med 2022; 23:e451-e455. [PMID: 35678459 PMCID: PMC9529772 DOI: 10.1097/pcc.0000000000003012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Pediatric Advanced Life Support (PALS) guidelines include weight-based epinephrine dosing recommendations of 0.01 mg/kg with a maximum of 1 mg, which corresponds to a weight of 100 kg. Actual practice patterns are unknown. DESIGN Multicenter cross-sectional survey regarding institutional practices for the transition from weight-based to flat dosing of epinephrine during cardiopulmonary resuscitation in PICUs. Exploratory analyses compared epinephrine dosing practices with several institutional characteristics using Fisher exact test. SETTING Internet-based survey. SUBJECTS U.S. PICU representatives (one per institution) involved in resuscitation systems of care. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 137 institutions surveyed, 68 (50%) responded. Most responding institutions are freestanding children's hospitals or dedicated children's hospitals within combined adult/pediatric hospitals (67; 99%); 55 (81%) are academic and 41 (60%) have PICU fellowship programs. Among respondents, institutional roles include PICU medical director (13; 19%), resuscitation committee member (23; 34%), and attending physician with interest in resuscitation (21; 31%). When choosing between weight-based and flat dosing, 64 respondents (94%) report using patient weight, 23 (34%) patient age, and five (7%) patient pubertal stage. Among those reporting using weight, 28 (44%) switch at 50 to less than 60 kg, 17 (27%) at 60 to less than 80 kg, five (8%) at 80 to less than 100 kg, and eight (12%) at greater than or equal to 100 kg. Among those reporting using age, four (17%) switch at 14 to less than 16 years, five (22%) at 16 to less than 18, and six (26%) at greater than or equal to 18. Twenty-nine respondents (43%) report using ideal body weight when dosing epinephrine in obese patients. Using patient age in choosing epinephrine dosing is more common in institutions that require Advanced Cardiac Life Support (ACLS) certification for some/all code team responders compared with institutions that do not require ACLS certification (52% vs 22%; p = 0.02). CONCLUSIONS The majority of PICUs surveyed report epinephrine dosing practices that are inconsistent with PALS guidelines.
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Affiliation(s)
- Martha F Kienzle
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Maya Dewan
- Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kiran B Hebbar
- Department of Pediatrics, Children's Hospital of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Vijay Srinivasan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ken Tegtmeyer
- Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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15
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Sveen W, Dewan M, Dexheimer JW. The Risk of Coding Racism into Pediatric Sepsis Care: The Necessity of Antiracism in Machine Learning. J Pediatr 2022; 247:129-132. [PMID: 35469891 DOI: 10.1016/j.jpeds.2022.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 03/16/2022] [Accepted: 04/15/2022] [Indexed: 11/27/2022]
Abstract
Machine learning holds the possibility of improving racial health inequalities by compensating for human bias and structural racism. However, unanticipated racial biases may enter during model design, training, or implementation and perpetuate or worsen racial inequalities if ignored. Pre-existing racial health inequalities could be codified into medical care by machine learning without clinicians being aware. To illustrate the importance of a commitment to antiracism at all stages of machine learning, we examine machine learning in predicting severe sepsis in Black children, focusing on the impacts of structural racism that may be perpetuated by machine learning and difficult to discover. To move toward antiracist machine learning, we recommend partnering with ethicists and experts in model development, enrolling representative samples for training, including socioeconomic inputs with proximate causal associations to racial inequalities, reporting outcomes by race, and committing to equitable models that narrow inequality gaps or at least have equal benefit.
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Affiliation(s)
- William Sveen
- Department of Pediatrics, University of Minnesota, Minneapolis, MN.
| | - Maya Dewan
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Judith W Dexheimer
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
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16
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Molloy M, Hagedorn P, Dewan M. Why Does Current Clinical Decision Support Frequently Fail to Support Clinical Decisions? Pediatr Crit Care Med 2022; 23:670-672. [PMID: 36165945 PMCID: PMC9523478 DOI: 10.1097/pcc.0000000000003000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthew Molloy
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Philip Hagedorn
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Maya Dewan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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17
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Fitzsimmons L, Dewan M, Dexheimer JW. Diversity in Machine Learning: A Systematic Review of Text-Based Diagnostic Applications. Appl Clin Inform 2022; 13:569-582. [PMID: 35613914 DOI: 10.1055/s-0042-1749119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE As the storage of clinical data has transitioned into electronic formats, medical informatics has become increasingly relevant in providing diagnostic aid. The purpose of this review is to evaluate machine learning models that use text data for diagnosis and to assess the diversity of the included study populations. METHODS We conducted a systematic literature review on three public databases. Two authors reviewed every abstract for inclusion. Articles were included if they used or developed machine learning algorithms to aid in diagnosis. Articles focusing on imaging informatics were excluded. RESULTS From 2,260 identified papers, we included 78. Of the machine learning models used, neural networks were relied upon most frequently (44.9%). Studies had a median population of 661.5 patients, and diseases and disorders of 10 different body systems were studied. Of the 35.9% (N = 28) of papers that included race data, 57.1% (N = 16) of study populations were majority White, 14.3% were majority Asian, and 7.1% were majority Black. In 75% (N = 21) of papers, White was the largest racial group represented. Of the papers included, 43.6% (N = 34) included the sex ratio of the patient population. DISCUSSION With the power to build robust algorithms supported by massive quantities of clinical data, machine learning is shaping the future of diagnostics. Limitations of the underlying data create potential biases, especially if patient demographics are unknown or not included in the training. CONCLUSION As the movement toward clinical reliance on machine learning accelerates, both recording demographic information and using diverse training sets should be emphasized. Extrapolating algorithms to demographics beyond the original study population leaves large gaps for potential biases.
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Affiliation(s)
- Lane Fitzsimmons
- College of Agriculture and Life Science, Cornell University, Ithaca, New York, United States
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Judith W Dexheimer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States.,Division of Emergency Medicine; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
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18
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Merritt C, Glisson M, Dewan M, Klein M, Zackoff M. Implementation and Evaluation of an Artificial Intelligence Driven Simulation to Improve Resident Communication With Primary Care Providers. Acad Pediatr 2022; 22:503-505. [PMID: 34923145 DOI: 10.1016/j.acap.2021.12.013] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/09/2021] [Accepted: 12/13/2021] [Indexed: 11/27/2022]
Abstract
Our artificial intelligence platform facilitated, evaluated, and provided real-time feedback on a standardized, simulated conversation. Learners evaluated the experience as equally effective to traditional education modalities and reported that it reinforced key communication elements, which would impact their future communication.
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Affiliation(s)
- Conor Merritt
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center (C Merritt, M Dewan, and M Zackoff), Cincinnati, Ohio.
| | - Michael Glisson
- Center for Simulation Research, Cincinnati Children's Hospital Medical Center (M Glisson and M Zackoff), Cincinnati, Ohio
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine (M Dewan, M Klein, and M Zackoff), Cincinnati, Ohio; Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center (C Merritt, M Dewan, and M Zackoff), Cincinnati, Ohio
| | - Melissa Klein
- Department of Pediatrics, University of Cincinnati College of Medicine (M Dewan, M Klein, and M Zackoff), Cincinnati, Ohio; Division of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center (M Klein), Cincinnati, Ohio
| | - Matthew Zackoff
- Department of Pediatrics, University of Cincinnati College of Medicine (M Dewan, M Klein, and M Zackoff), Cincinnati, Ohio; Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center (C Merritt, M Dewan, and M Zackoff), Cincinnati, Ohio; Center for Simulation Research, Cincinnati Children's Hospital Medical Center (M Glisson and M Zackoff), Cincinnati, Ohio
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19
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Frazier M, Dewan M, Tegtmeyer K. Who Let All These People In? Hosp Pediatr 2022; 12:e129-e130. [PMID: 35288740 DOI: 10.1542/hpeds.2022-006553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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Affiliation(s)
- Maya Dewan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Biomedical Informatics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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21
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Frazier M, Dewan M, Keller-Smith R, Shoemaker J, Stewart C, Tegtmeyer K. Improving CPR Quality by Using a Real-Time Feedback Defibrillator During Pediatric Simulation Training. Pediatr Emerg Care 2022; 38:e993-e996. [PMID: 35100789 DOI: 10.1097/pec.0000000000002370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess the effectiveness of a defibrillator with real-time feedback during code team training to improve adherence to the American Heart Association (AHA) resuscitation guidelines. METHODS This is a retrospective cohort study designed to compare pediatric resident adherence to the AHA cardiopulmonary resuscitation guidelines before and after use of real-time feedback defibrillator during code team training simulation. After institution of a real-time feedback defibrillator, first-year resident's adherence to the AHA guidelines for chest compression rate (CCR), fraction, and depth during code team training from January 2017 to December 2018 was analyzed. It was then compared with results of a previously published study from our institution that analyzed the CCR and fraction from January 2015 to January 2016, before the implementation of a defibrillator with real-time feedback. RESULTS We compared 19 eligible session preintervention and 36 postintervention sessions. Chest compression rate and chest compression fraction (CCF) were assessed preintervention and postintervention. The depth of compression was only available postintervention. There was improvement in the proportion of code team training sessions with mean compression rate (74% preintervention vs 100% postintervention, P = 0.003) and mean CCF (79% vs 97%, P = 0.04) in adherence with the AHA guideline. CONCLUSIONS The use of real-time feedback defibrillators improved the adherence to the AHA cardiopulmonary resuscitation guidelines for CCF and CCR during pediatric resident simulation.
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Affiliation(s)
- Maria Frazier
- From the Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center
| | | | - Rachel Keller-Smith
- Center for Simulation and Research, Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Jamie Shoemaker
- Center for Simulation and Research, Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Claire Stewart
- Division of Critical Care, Nationwide Children's Hospital, Columbus, OH
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22
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Dewan M. Use of Procalcitonin in Pediatric Sepsis is Low-Value Care. J Pediatric Infect Dis Soc 2022; 11:31-32. [PMID: 34338798 DOI: 10.1093/jpids/piab068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/11/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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23
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Sosa T, Mayer B, Chakkalakkal B, Drozd A, Hater K, Johnson A, Nasr A, Seger BM, Meyer R, Dewan M, White CM, Brady PW. Improving Shared Situation Awareness for High-risk Therapies in Hospitalized Children. Hosp Pediatr 2022; 12:37-46. [PMID: 34859255 DOI: 10.1542/hpeds.2021-006193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND High-risk therapies (HRTs), including medications and medical devices, are an important driver of preventable harm in children's hospitals. To facilitate shared situation awareness (SA) and thus targeted harm prevention, we aimed to increase the percentage of electronic health record (EHR) alerts with the correct descriptor of an HRT from 11% to 100% on a high-acuity hospital unit over a 6-month period. METHODS The interdisciplinary team defined an HRT as a medication or device with a significant risk for harm that required heightened awareness. Our aim for interventions was to (1) educate staff on a new HRT algorithm; (2) develop a comprehensive table of HRTs, risks, and mitigation plans; (3) develop bedside signs for patients receiving HRTs; and (4) restructure unit huddles. Qualitative interviews with families, nurses, and medical teams were used to assess shared SA and inform the development and adaptation of interventions. The primary outcome metric was the percentage of EHR alerts for an HRT that contained a correct descriptor of the therapy for use by the care team and institutional safety leaders. RESULTS The percentage of EHR alerts with a correct HRT descriptor increased from an average of 11% to 96%, with special cause variation noted on a statistical process control chart. Using qualitative interview data, we identified critical awareness gaps, including establishing a shared mental model between nursing staff and the medical team as well as engagement of families at the bedside to monitor for complications. CONCLUSIONS Explicit, structured processes and huddles can increase HRT SA among the care team, patient, and family.
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Affiliation(s)
| | | | | | | | | | | | | | - Brandy M Seger
- James M. Anderson Center for Health System Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Maya Dewan
- Critical Care Medicine
- Biomedical Informatics
- James M. Anderson Center for Health System Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christine M White
- Divisions of Hospital Medicine
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Patrick W Brady
- Divisions of Hospital Medicine
- James M. Anderson Center for Health System Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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24
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Dewan M, Soberano B, Sosa T, Zackoff M, Hagedorn P, Brady PW, Chima RS, Stalets EL, Moore L, Britto M, Sutton RM, Nadkarni V, Tegtmeyer K, Wolfe H. Assessment of a Situation Awareness Quality Improvement Intervention to Reduce Cardiac Arrests in the PICU. Pediatr Crit Care Med 2022; 23:4-12. [PMID: 34417417 PMCID: PMC8738107 DOI: 10.1097/pcc.0000000000002816] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To use improved situation awareness to decrease cardiopulmonary resuscitation events by 25% over 18 months and demonstrate process and outcome sustainability. DESIGN Structured quality improvement initiative. SETTING Single-center, 35-bed quaternary-care PICU. PATIENTS All patients admitted to the PICU from February 1, 2017, to December 31, 2020. INTERVENTIONS Interventions targeted situation awareness and included bid safety huddles, bedside mitigation signs and huddles, smaller pod-based huddles, and an automated clinical decision support tool to identify high-risk patients. MEASUREMENTS AND MAIN RESULTS The primary outcome metric, cardiopulmonary resuscitation event rate per 1,000 patient-days, decreased from a baseline of 3.1-1.5 cardiopulmonary resuscitation events per 1,000 patient-days or by 52%. The secondary outcome metric, mortality rate, decreased from a baseline of 6.6 deaths per 1,000 patient-days to 3.6 deaths per 1,000 patient-days. Process metrics included percent of clinical deterioration events predicted, which increased from 40% to 67%, and percent of high-risk patients with shared situation awareness, which increased from 43% to 71%. Balancing metrics included time spent in daily safety huddle, median 0.4 minutes per patient (interquartile range, 0.3-0.5), and a number needed to alert of 16 (95% CI, 14-25). Neither unit acuity as measured by Pediatric Risk of Mortality III scores nor the percent of deaths in patients with do-not-attempt resuscitation orders or electing withdrawal of life-sustaining technologies changed over time. CONCLUSIONS Interprofessional teams using shared situation awareness may reduce cardiopulmonary resuscitation events and, thereby, improve outcomes.
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Affiliation(s)
- Maya Dewan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Blaise Soberano
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Tina Sosa
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Matthew Zackoff
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Philip Hagedorn
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick W Brady
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Ranjit S. Chima
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Erika L. Stalets
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lindsey Moore
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Maria Britto
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Robert M Sutton
- Department of Anesthesia and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Vinay Nadkarni
- Department of Anesthesia and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Ken Tegtmeyer
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Heather Wolfe
- Department of Anesthesia and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, PA
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25
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Abstract
The number of disorders that benefit from hematopoietic stem cell transplantation (HSCT) has increased, causing the overall number of HSCT to increase accordingly. Disorders treated by HSCT include malignancy, benign hematologic disorders, bone marrow failure syndromes, and certain genetic diagnoses. Thus, understanding the complications, diagnostic workup of complications, and subsequent treatments has become increasingly important. One such category of complications includes the pulmonary system. While the overall incidence of pulmonary complications has decreased, the morbidity and mortality of these complications remain high. Therefore, having a clear differential diagnosis and diagnostic workup is imperative. Pulmonary complications can be subdivided by time of onset and whether the complication is infectious or non-infectious. While most infectious complications have clear diagnostic criteria and treatment courses, the non-infectious complications are more varied and not always well understood. This review article discusses pulmonary complications of HSCT recipients and outlines current knowledge, gaps in knowledge, and current treatment of each complication. This article includes some adult studies, as there is a significant paucity of pediatric data.
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Affiliation(s)
- Taylor Fitch
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Kasiani C Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Maya Dewan
- Division of Critical Care, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Christopher Towe
- Division of Pulmonology, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - Christopher Dandoy
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center (CCHMC), University of Cincinnati School of Medicine, Cincinnati, OH, United States
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26
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Lauridsen KG, Morgan RW, Dewan M, Gawronski O, Sen AI. In-hospital cardiac arrest characteristics, CPR quality, and outcomes in children with COVID-19. Resuscitation 2021; 169:39-40. [PMID: 34673154 PMCID: PMC8522673 DOI: 10.1016/j.resuscitation.2021.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Kasper G Lauridsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark; Emergency Department, Randers Regional Hospital, Denmark; Center for Pediatric Resuscitation, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, USA.
| | - Ryan W Morgan
- Center for Pediatric Resuscitation, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, USA
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, USA
| | - Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Bambino Gesù Children's Hospital IRCCS, Italy
| | - Anita I Sen
- Department of Pediatrics, Columbia University, USA
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27
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Frazier ME, Brown SR, O'Halloran A, Raymond T, Hanna R, Niles DE, Kleinman M, Sutton RM, Roberts J, Tegtmeyer K, Wolfe HA, Nadkarni V, Dewan M. Risk factors and outcomes for recurrent paediatric in-hospital cardiac arrest: Retrospective multicenter cohort study. Resuscitation 2021; 169:60-66. [PMID: 34673152 DOI: 10.1016/j.resuscitation.2021.10.015] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/09/2021] [Accepted: 10/07/2021] [Indexed: 10/20/2022]
Abstract
AIM OF STUDY Recurrent in-hospital cardiac arrest (IHCA) is associated with morbidity and mortality in adults. We aimed to describe the risk factors and outcomes for paediatric recurrent IHCA. METHODS Retrospective cohort study of patients ≤18 years old with single or recurrent IHCA. Recurrent IHCA was defined as ≥2 IHCA within the same hospitalization. Categorical variables expressed as percentages and compared via Chi square test. Continuous variables expressed as medians with interquartile ranges and compared via rank sum test. Outcomes assessed in a propensity match cohort. RESULTS From July 1, 2015 to January 26, 2021, 139/894 (15.5%) patients experienced recurrent IHCA. Compared to patients with a single IHCA, recurrent IHCA patients were more likely to be trauma and less likely to be surgical cardiac patients. Median duration of cardiopulmonary resuscitation (CPR) was shorter in the recurrent IHCA (5 vs. 11 min; p < 0.001) with no difference in IHCA location or immediate cause of CPR. Patients with recurrent IHCA had worse survival to intensive care unit (ICU) discharge (31% vs. 52%; p < 0.001), and worse survival to hospital discharge (30% vs. 48%; p < 0.001) in unadjusted analyses and after propensity matching, patients with recurrent IHCA still had worse survival to ICU (34% vs. 67%; p < 0.001) and hospital (31% vs. 64%; p < 0.001) discharge. CONCLUSION When examining those with a single vs. a recurrent IHCA, event and patient factors including more pre-existing conditions and shorter duration of CPR were associated with risk for recurrent IHCA. Recurrent IHCA is associated with worse survival outcomes following propensity matching.
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Affiliation(s)
| | - Stephanie R Brown
- University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA; Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Amanda O'Halloran
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Children's Hospital of San Antonio, San Antonio, TX, USA
| | - Tia Raymond
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Richard Hanna
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Children's Hospital of San Antonio, San Antonio, TX, USA
| | - Dana E Niles
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Monica Kleinman
- Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Robert M Sutton
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Children's Hospital of San Antonio, San Antonio, TX, USA
| | - Joan Roberts
- Ospedale Pediatrico Bambino Gesù, Rome, Italy; Alberta Children's Hospital, Calgary, AB, Canada
| | - Ken Tegtmeyer
- Riley Hospital for Children, Indianapolis, IN, USA; Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Heather A Wolfe
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Children's Hospital of San Antonio, San Antonio, TX, USA
| | - Vinay Nadkarni
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Children's Hospital of San Antonio, San Antonio, TX, USA
| | - Maya Dewan
- Riley Hospital for Children, Indianapolis, IN, USA; Children's Hospital at Westmead, Sydney, NSW, Australia; Stollery Children's Hospital, Edmonton, AB, Canada
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28
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Sosa T, Sitterding M, Dewan M, Coleman M, Seger B, Bedinghaus K, Hawkins D, Maddock B, Hausfeld J, Falcone R, Brady PW, Simmons J, White CM. Optimizing Situation Awareness to Reduce Emergency Transfers in Hospitalized Children. Pediatrics 2021; 148:peds.2020-034603. [PMID: 34599089 DOI: 10.1542/peds.2020-034603] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Interventions to improve care team situation awareness (SA) are associated with reduced rates of unrecognized clinical deterioration in hospitalized children. By addressing themes from recent safety events and emerging corruptors to SA in our system, we aimed to decrease emergency transfers (ETs) to the ICU by 50% over 10 months. METHODS An interdisciplinary team of physicians, nurses, respiratory therapists, and families convened to improve the original SA model for clinical deterioration and address communication inadequacies and evolving technology in our inpatient system. The key drivers included the establishment of a shared mental model, psychologically safe escalation, and efficient and effective SA tools. Novel interventions including the intentional inclusion of families and the interdisciplinary team in huddles, a mental model checklist, door signage, and an electronic health record SA navigator were evaluated via a time series analysis. Sequential inpatient-wide testing of the model allowed for iteration and consensus building across care teams and families. The primary outcome measure was ETs, defined as any ICU transfer in which the patient receives intubation, inotropes, or ≥3 fluid boluses within 1 hour. RESULTS The rate of ETs per 10 000 patient-days decreased from 1.34 to 0.41 during the study period. This coincided with special cause improvement in process measures, including risk recognition before medical response team activation and the use of tools to facilitate shared SA. CONCLUSIONS An innovative, proactive, and reliable process to predict, prevent, and respond to clinical deterioration was associated with a nearly 70% reduction in ETs.
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Affiliation(s)
| | | | - Maya Dewan
- Critical Care Medicine.,Biomedical Informatics.,Departments of Pediatrics
| | | | - Brandy Seger
- James M. Anderson Center for Health Systems Excellence
| | | | | | - Benjamin Maddock
- Pediatric Residency Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Richard Falcone
- Pediatric General and Thoracic Surgery.,Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Patrick W Brady
- Divisions of Hospital Medicine.,Departments of Pediatrics.,James M. Anderson Center for Health Systems Excellence
| | - Jeffrey Simmons
- Divisions of Hospital Medicine.,Departments of Pediatrics.,James M. Anderson Center for Health Systems Excellence
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29
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Lanziotti VS, Dewan M, Behrens D, Bulut Y, Miller J, Ong JSM, Kudchadkar S. Gender Equity and Diversity in Pediatric Critical Care Medicine: We Must Do Better. J Pediatr Intensive Care 2021. [DOI: 10.1055/s-0041-1735871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Vanessa Soares Lanziotti
- Maternal and Child Health Postgraduate Program, Institute of Pediatrics, Federal University of Rio De Janeiro, Rio De Janeiro, Brazil
| | - Maya Dewan
- Division of Critical Care Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, United States
| | - Deanna Behrens
- Pediatric Critical Care Faculty, Children's Hospital, Park Ridge, Illinois, United States
| | - Yonca Bulut
- Department of Pediatrics, Division of Pediatric Critical Care, David Geffen School of Medicine at UCLA, UCLA Mattel Children's Hospital, Los Angeles, California, United States
| | - Jenna Miller
- Department of Pediatrics, Division of Pediatric Critical Care, Department of Pediatrics, University of Missouri, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Jacqueline S. M. Ong
- Division of Paediatric Critical Care Khoo Teck Puat, National University Children's Medical Institute, National University Health System, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sapna Kudchadkar
- Anesthesiology and Critical Care Medicine, Pediatrics, and Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Charlotte Bloomberg Children's Center, Baltimore, Maryland, United States
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30
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Affiliation(s)
- Maya Dewan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Heather Wolfe
- Department of Anesthesia and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Erika L. Stalets
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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31
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Pfeiffer S, Lauridsen KG, Wenger J, Hunt EA, Haskell S, Atkins DL, Duval-Arnould JM, Knight LJ, Cheng A, Gilfoyle E, Su F, Balikai S, Skellett S, Hui MY, Niles DE, Roberts JS, Nadkarni VM, Tegtmeyer K, Dewan M. Code Team Structure and Training in the Pediatric Resuscitation Quality International Collaborative. Pediatr Emerg Care 2021; 37:e431-e435. [PMID: 31045955 PMCID: PMC8809371 DOI: 10.1097/pec.0000000000001748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Code team structure and training for pediatric in-hospital cardiac arrest are variable. There are no data on the optimal structure of a resuscitation team. The objective of this study is to characterize the structure and training of pediatric code teams in sites participating in the Pediatric Resuscitation Quality Collaborative. METHODS From May to July 2017, an anonymous voluntary survey was distributed to 18 sites in the international Pediatric Resuscitation Quality Collaborative. The survey content was developed by the study investigators and iteratively adapted by consensus. Descriptive statistics were calculated. RESULTS All sites have a designated code team and hospital-wide code team activation system. Code team composition varies greatly across sites, with teams consisting of 3 to 17 members. Preassigned roles for code team members before the event occur at 78% of sites. A step stool and backboard are used during resuscitations in 89% of surveyed sites. Cardiopulmonary resuscitation (CPR) feedback is used by 72% of the sites. Of those sites that use CPR feedback, all use an audiovisual feedback device incorporated into the defibrillator and 54% use a CPR coach. Multidisciplinary and simulation-based code team training is conducted by 67% of institutions. CONCLUSIONS Code team structure, equipment, and training vary widely in a survey of international children's hospitals. The variations in team composition, role assignments, equipment, and training described in this article will be used to facilitate future studies regarding the impact of structure and training of code teams on team performance and patient outcomes.
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Affiliation(s)
- Stephen Pfeiffer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kasper Glerup Lauridsen
- Department of Internal Medicine, Randers Regional Hospital
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
| | | | - Elizabeth A. Hunt
- Department of Anesthesiology and Critical Care Medicine, Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sarah Haskell
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Dianne L. Atkins
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Jordan M. Duval-Arnould
- Department of Anesthesiology and Critical Care Medicine, Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lynda J. Knight
- Revive Initiative for Resuscitation Excellence, Stanford Children’s Health, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA
| | - Adam Cheng
- Departments of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Departments of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Elaine Gilfoyle
- Departments of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Departments of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Felice Su
- Revive Initiative for Resuscitation Excellence, Stanford Children’s Health, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA
| | - Shilpa Balikai
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Sophie Skellett
- Department of Paediatric Intensive Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Mok Yee Hui
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
| | - Dana E. Niles
- The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Pediatric Resuscitation Quality Collaborative Investigators
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Internal Medicine, Randers Regional Hospital
- Research Center for Emergency Medicine, Aarhus University Hospital, Denmark
- Seattle Children’s Hospital, Seattle, WA
- Department of Anesthesiology and Critical Care Medicine, Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, MD
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
- Revive Initiative for Resuscitation Excellence, Stanford Children’s Health, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA
- Departments of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Departments of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Paediatric Intensive Care, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore
- The Children’s Hospital of Philadelphia, Philadelphia, PA
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32
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Innis K, Hasson D, Bodilly L, Sveen W, Stalets EL, Dewan M. Do I Need Proof of the Culprit? Decreasing Respiratory Viral Testing in Critically Ill Patients. Hosp Pediatr 2020; 11:e1-e5. [PMID: 33323392 DOI: 10.1542/hpeds.2020-000943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | | | | | - Erika L Stalets
- Divisions of Critical Care Medicine and.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Maya Dewan
- Divisions of Critical Care Medicine and .,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
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33
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Sosa T, Ferris S, Frese C, Hacker D, Dewan M, Brady PW. Comparing Two Proximal Measures of Unrecognized Clinical Deterioration in Children. J Hosp Med 2020; 15:673-676. [PMID: 33147135 PMCID: PMC7657656 DOI: 10.12788/jhm.3515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/04/2020] [Indexed: 11/20/2022]
Abstract
Critical deterioration events (CDEs) and emergency transfers (ETs) are two proximal measures to cardiopulmonary arrest, and both aim to evaluate how systems recognize and respond to clinical deterioration in children. This retrospective observational study sought to (1) characterize CDEs and ETs by timing, overlap, and intervention category, and (2) evaluate the performance of the watcher identification system and the pediatric early warning score (PEWS) to identify patients who experience these events. A total of 359 CDEs and 88 ETs occurred during the study period. Respiratory events were most common and accounted for 80.5% of CDEs and 47.7% of ETs. A narrow majority of patients were identified as watchers (55.4% of CDEs and 51.1% of ETs). In total, 85.5% of CDEs and 87.5% of ETs were identified as watchers, elevated PEWS, or both. Opportunities exist for improved escalation plans for high-risk patients to prevent the need for emergent intervention.
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Affiliation(s)
- Tina Sosa
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Corresponding Author: Tina Sosa, MD; ; Twitter: @TinaKSosa
| | - Sarah Ferris
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Carol Frese
- Department of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Deborah Hacker
- Department of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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34
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Soberano BT, Brady P, Yunger T, Jones R, Stoneman E, Sosa T, Stalets EL, Zackoff M, Chima R, Tegtmeyer K, Dewan M. The Effects of Care Team Roles on Situation Awareness in the Pediatric Intensive Care Unit: A Prospective Cross-Sectional Study. J Hosp Med 2020; 15:594-597. [PMID: 32853138 PMCID: PMC7850634 DOI: 10.12788/jhm.3449] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/17/2020] [Indexed: 11/20/2022]
Abstract
Improved situation awareness (SA) decreases rates of clinical deterioration in the pediatric inpatient setting. We used a prospective, cross-sectional, observational study to measure interprofessional care team SA for a pediatric intensive care unit (PICU) patients. The resident, bedside nurse, and respiratory therapist for each patient were surveyed regarding high clinical deterioration risk status as defined by clinical criteria identified by the PICU fellow or attending and mitigation plan. From March 2018 to July 2019, we surveyed 400 care team trios caring for 73 high-risk patients. Nurses identified the patient's risk status correctly for 375 of 400 patients (94%), respiratory therapists, 380 (95%; P = .4), and residents, 349 (87%; P = .002). For the 73 high-risk patients, nurses were correct 82% of the time, respiratory therapists, 85%, P = .7, and residents, 67%, P = .04. Interventions targeting resident SA are needed within the PICU, especially for high-risk patients.
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Affiliation(s)
- Blaise T Soberano
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Toni Yunger
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Rhonda Jones
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Erin Stoneman
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Tina Sosa
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Matthew Zackoff
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ranjit Chima
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ken Tegtmeyer
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Corresponding Author: Maya Dewan, MD, MPH; ; Telephone: 215-756-7060; Twitter: @mommimaya
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35
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Morgan RW, Kienzle M, Sen AI, Kilbaugh TJ, Dewan M, Raymond TT, Himebauch AS, Berg RA, Tegtmeyer K, Nadkarni VM, Topjian AA, Sutton RM, Wolfe HA. Pediatric Resuscitation Practices During the Coronavirus Disease 2019 Pandemic. Pediatr Crit Care Med 2020; 21:e651-e660. [PMID: 32618677 PMCID: PMC7340134 DOI: 10.1097/pcc.0000000000002512] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES While most pediatric coronavirus disease 2019 cases are not life threatening, some children have severe disease requiring emergent resuscitative interventions. Resuscitation events present risks to healthcare provider safety and the potential for compromised patient care. Current resuscitation practices and policies for children with suspected/confirmed coronavirus disease 2019 are unknown. DESIGN Multi-institutional survey regarding inpatient resuscitation practices during the coronavirus disease 2019 pandemic. SETTING Internet-based survey. SUBJECTS U.S. PICU representatives (one per institution) involved in resuscitation system planning and oversight. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 130 institutions surveyed, 78 (60%) responded. Forty-eight centers (62%) had admitted coronavirus disease 2019 patients; 26 (33%) reported code team activation for patients with suspected/confirmed coronavirus disease 2019. Sixty-seven respondents (86%) implemented changes to inpatient emergency response systems. The most common changes were as follows: limited number of personnel entering patient rooms (75; 96%), limited resident involvement (71; 91%), and new or refined team roles (74; 95%). New or adapted technology is being used for coronavirus disease 2019 resuscitations in 58 centers (74%). Most institutions (57; 73%) are using enhanced personal protective equipment for all coronavirus disease 2019 resuscitation events; 18 (23%) have personal protective equipment policies dependent on the performance of aerosol generating procedures. Due to coronavirus disease 2019, most respondents are intubating earlier during cardiopulmonary resuscitation (56; 72%), utilizing video laryngoscopy (67; 86%), pausing chest compressions during laryngoscopy (56; 72%), and leaving patients connected to the ventilator during cardiopulmonary resuscitation (56; 72%). Responses were varied regarding airway personnel, prone cardiopulmonary resuscitation, ventilation strategy during cardiopulmonary resuscitation without an airway in place, and extracorporeal cardiopulmonary resuscitation. Most institutions (46; 59%) do not have policies regarding limitations of resuscitation efforts in coronavirus disease 2019 patients. CONCLUSIONS Most U.S. pediatric institutions rapidly adapted their resuscitation systems and practices in response to the coronavirus disease 2019 pandemic. Changes were commonly related to team members and roles, personal protective equipment, and airway and breathing management, reflecting attempts to balance quality resuscitation with healthcare provider safety.
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Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Martha Kienzle
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Anita I Sen
- Department of Pediatrics, Columbia University, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Tia T Raymond
- Cardiac Intensive Care Unit, Department of Pediatrics, Medical City Children's Hospital, Dallas, TX
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Dewan M, Vidrine R, Zackoff M, Paff Z, Seger B, Pfeiffer S, Hagedorn P, Stalets EL. Design, Implementation, and Validation of a Pediatric ICU Sepsis Prediction Tool as Clinical Decision Support. Appl Clin Inform 2020; 11:218-225. [PMID: 32215893 DOI: 10.1055/s-0040-1705107] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Sepsis is an uncontrolled inflammatory reaction caused by infection. Clinicians in the pediatric intensive care unit (PICU) developed a paper-based tool to identify patients at risk of sepsis. To improve the utilization of the tool, the PICU team integrated the paper-based tool as a real-time clinical decision support (CDS) intervention in the electronic health record (EHR). OBJECTIVE This study aimed to improve identification of PICU patients with sepsis through an automated EHR-based CDS intervention. METHODS A prospective cohort study of all patients admitted to the PICU from May 2017 to May 2019. A CDS intervention was implemented in May 2018. The CDS intervention screened patients for nonspecific sepsis criteria, temperature dysregulation and a blood culture within 6 hours. Following the screening, an interruptive alert prompted nursing staff to complete a perfusion screen to assess for clinical signs of sepsis. The primary alert performance outcomes included sensitivity, specificity, and positive and negative predictive value. The secondary clinical outcome was completion of sepsis management tasks. RESULTS During the 1-year post implementation period, there were 45.0 sepsis events per 1,000 patient days over 10,805 patient days. The sepsis alert identified 392 of the 436 sepsis episodes accurately with sensitivity of 92.5%, specificity of 95.6%, positive predictive value of 46.0%, and negative predictive value of 99.7%. Examining only patients with severe sepsis confirmed by chart review, test characteristics fell to a sensitivity of 73.3%, a specificity of 92.5%. Prior to the initiation of the alert, 18.6% (13/70) of severe sepsis patients received recommended sepsis interventions. Following the implementation, 34% (27/80) received these interventions in the time recommended, p = 0.04. CONCLUSION An EHR CDS intervention demonstrated strong performance characteristics and improved completion of recommended sepsis interventions.
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Affiliation(s)
- Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States.,Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States.,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Rhea Vidrine
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States.,Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Matthew Zackoff
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States.,Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Zachary Paff
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Brandy Seger
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Stephen Pfeiffer
- Division of Critical Care Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Philip Hagedorn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States.,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Erika L Stalets
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States.,Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
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Vidrine R, Zackoff M, Paff Z, Seger B, Satterlee M, Buenaventura E, Smith C, Pfeiffer S, Sahay RD, Stalets EL, Dewan M. Improving Timely Recognition and Treatment of Sepsis in the Pediatric ICU. Jt Comm J Qual Patient Saf 2020; 46:299-307. [PMID: 32201121 DOI: 10.1016/j.jcjq.2020.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/03/2020] [Accepted: 02/13/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Sepsis is a leading cause of pediatric mortality worldwide. The implementation of sepsis bundles and clinical decision support (CDS) tools have been useful in improving sepsis recognition and treatment. METHODS Interventions targeted the pediatric ICU (PICU) sepsis identification process and focused on implementation of multidisciplinary sepsis huddles prompted by an automated CDS tool. The primary outcome measure was days between delayed sepsis recognition, with secondary outcome measures of the percentages of patients receiving goal-directed evidence-based sepsis therapies, including antibiotics within 1 hour, rapid fluid bolus within 20 minutes, and lactate measurement within 1 hour. The researchers also tracked median time to antibiotics. RESULTS Average days between delayed sepsis recognition improved from one episode every 9 days to one episode every 28 days. The percentage of patients who received antibiotics within 1 hour improved from 33.9% to 45.5%, received a fluid bolus within 20 minutes increased from 54.7% to 61.8%, and had a lactate measured within 1 hour increased from 59.4% to 71.1% post-CDS alert; none were statistically significant. Median time to antibiotics prior to CDS alert implementation was 1.53 hours, with improvement to 1.05 hours postimplementation (p = 0.03). CONCLUSION Implementation of multidisciplinary sepsis huddles and an automated CDS alert in the PICU led to an improvement in days between delayed sepsis recognition and a significant improvement in time to antibiotics.
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Dewan M, Muthu N, Shelov E, Bonafide CP, Brady P, Davis D, Kirkendall ES, Niles D, Sutton RM, Traynor D, Tegtmeyer K, Nadkarni V, Wolfe H. Performance of a Clinical Decision Support Tool to Identify PICU Patients at High Risk for Clinical Deterioration. Pediatr Crit Care Med 2020; 21:129-135. [PMID: 31577691 PMCID: PMC7007854 DOI: 10.1097/pcc.0000000000002106] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the translation of a paper high-risk checklist for PICU patients at risk of clinical deterioration to an automated clinical decision support tool. DESIGN Retrospective, observational cohort study of an automated clinical decision support tool, the PICU Warning Tool, adapted from a paper checklist to predict clinical deterioration events in PICU patients within 24 hours. SETTING Two quaternary care medical-surgical PICUs-The Children's Hospital of Philadelphia and Cincinnati Children's Hospital Medical Center. PATIENTS The study included all patients admitted from July 1, 2014, to June 30, 2015, the year prior to the initiation of any focused situational awareness work at either institution. INTERVENTIONS We replicated the predictions of the real-time PICU Warning Tool by retrospectively querying the institutional data warehouse to identify all patients that would have flagged as high-risk by the PICU Warning Tool for their index deterioration. MEASUREMENTS AND MAIN RESULTS The primary exposure of interest was determination of high-risk status during PICU admission via the PICU Warning Tool. The primary outcome of interest was clinical deterioration event within 24 hours of a positive screen. The date and time of the deterioration event was used as the index time point. We evaluated the sensitivity, specificity, positive predictive value, and negative predictive value of the performance of the PICU Warning Tool. There were 6,233 patients evaluated with 233 clinical deterioration events experienced by 154 individual patients. The positive predictive value of the PICU Warning Tool was 7.1% with a number needed to screen of 14 patients for each index clinical deterioration event. The most predictive of the individual criteria were elevated lactic acidosis, high mean airway pressure, and profound acidosis. CONCLUSIONS Performance of a clinical decision support translation of a paper-based tool showed inferior test characteristics. Improved feasibility of identification of high-risk patients using automated tools must be balanced with performance.
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Affiliation(s)
- Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Naveen Muthu
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Eric Shelov
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Patrick Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Daniela Davis
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Eric S. Kirkendall
- Department of Pediatrics, Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
| | - Dana Niles
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Robert M. Sutton
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Danielle Traynor
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Ken Tegtmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Heather Wolfe
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA
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Chang TP, Raymond T, Dewan M, MacKinnon R, Whitfill T, Harwayne-Gidansky I, Doughty C, Frisell K, Kessler D, Wolfe H, Auerbach M, Rutledge C, Mitchell D, Jani P, Walsh CM. The effect of an International competitive leaderboard on self-motivated simulation-based CPR practice among healthcare professionals: A randomized control trial. Resuscitation 2019; 138:273-281. [PMID: 30946919 DOI: 10.1016/j.resuscitation.2019.02.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/11/2019] [Accepted: 02/18/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Little is known about how best to motivate healthcare professionals to engage in frequent cardiopulmonary resuscitation (CPR) refresher skills practice. A competitive leaderboard for simulated CPR can encourage self-directed practice on a small scale. The study aimed to determine if a large-scale, multi-center leaderboard improved simulated CPR practice frequency and CPR performance among healthcare professionals. METHODS This was a multi-national, randomized cross-over study among 17 sites using a competitive online leaderboard to improve simulated practice frequency and CPR performance. All sites placed a Laerdal® ResusciAnne or ResusciBaby QCPR manikin in 1 or more clinical units - emergency department, ICU, etc. - in easy reach for 8 months. These simulators provide visual feedback during 2-minute compressions-only CPR and a performance score. Sites were randomly assigned to the intervention for the first 4-months or the second 4-months. Following any CPR practice by a healthcare professional, participants uploaded scores and an optional 'selfie' photo to the leaderboard. During the intervention phase, the leaderboard displayed ranked scores and high scores earned digital badges. The leaderboard did not display control phase participants. Outcomes included CPR practice frequency and mean compression score, using non-parametric statistics for analyses. RESULTS Nine-hundred nineteen participants completed 1850 simulated CPR episodes. Exposure to the leaderboard yielded 1.94 episodes per person compared to 2.14 during the control phase (p = 0.99). Mean CPR performance participants did not differ between phases: 90.7 vs. 89.3 (p = 0.19). CONCLUSION A competitive leaderboard was not associated with an increase in self-directed simulated CPR practice or improved performance.
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Affiliation(s)
- Todd P Chang
- Division of Emergency Medicine & Transport, Children's Hospital Los Angeles, Keck School of Medicine at University of Southern California, United States.
| | - Tia Raymond
- Pediatric Cardiac Critical Care, Medical City Children's Hospital, Dallas, TX, United States
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States; Division of Critical Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Ralph MacKinnon
- Department of Paediatric Anaesthesia, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Travis Whitfill
- Departments of Pediatrics and Emergency Medicine, Yale University School, Division of Medicine, New Haven CT, United States
| | - Ilana Harwayne-Gidansky
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stony Brook Children's Hospital, Stony Brook, NY, United States
| | - Cara Doughty
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
| | | | - David Kessler
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, United States
| | - Heather Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Marc Auerbach
- Departments of Pediatrics and Emergency Medicine, Yale University School, Division of Medicine, New Haven CT, United States
| | - Chrystal Rutledge
- Division of Pediatric Critical Care, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Diana Mitchell
- Department of Pediatrics, Section of Critical Care Medicine, Comer Children's Hospital, The University of Chicago Medicine, Chicago, IL, United States
| | - Priti Jani
- Department of Pediatrics, Section of Critical Care Medicine, Comer Children's Hospital, The University of Chicago Medicine, Chicago, IL, United States
| | - Catharine M Walsh
- Department of Paediatrics, the Research and Learning Institutes, Hospital for Sick Children, University of Toronto, Toronto, Canada
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Dewan M, Herrmann LE, Tchou MJ, Parsons A, Muthu N, Tenney-Soeiro R, Fieldston E, Lindell RB, Dziorny A, Gosdin C, Bamat TW. Development and Evaluation of High-Value Pediatrics: A High-Value Care Pediatric Resident Curriculum. Hosp Pediatr 2018; 8:785-792. [PMID: 30425056 DOI: 10.1542/hpeds.2018-0115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Low-value health care is pervasive in the United States, and clinicians need to be trained to be stewards of health care resources. Despite a mandate by the Accreditation Council for Graduate Medical Education to educate trainee physicians on cost awareness, only 10% of pediatric residency programs have a high-value care (HVC) curriculum. To meet this need, we set out to develop and evaluate the impact of High-Value Pediatrics, an open-access HVC curriculum. High-Value Pediatrics is a 3-part curriculum that includes 4 standardized didactics, monthly interactive morning reports, and an embedded HVC improvement project. Curriculum evaluation through an anonymous, voluntary survey revealed an improvement in the self-reported knowledge of health care costs, charges, reimbursement, and value (P < .05). Qualitative results revealed self-reported behavior changes, and HVC improvement projects resulted in higher-value patient care. The implementation of High-Value Pediatrics is feasible and reveals improved knowledge and attitudes about HVC. HVC improvement projects augmented curricular knowledge gains and revealed behavior changes. It is imperative that formal high-value education be taught to every pediatric trainee to lead the culture change that is necessary to turn the tide against low-value health care. In addition, simultaneous work on faculty education and attention to the hidden curriculum of low-value care is needed for sustained and long-term improvements.
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Affiliation(s)
- Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; .,Critical Care Medicine, and.,James M. Anderson Center for Health Systems Excellence and
| | - Lisa E Herrmann
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | - Michael J Tchou
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence and.,Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | | | - Naveen Muthu
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rebecca Tenney-Soeiro
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Evan Fieldston
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert B Lindell
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine and
| | - Adam Dziorny
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine and
| | - Craig Gosdin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | - Tara W Bamat
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Zackoff MW, Iyer S, Dewan M. An overarching approach for acute care delivery: extension of the acute care model to the entire inpatient admission. Transl Pediatr 2018; 7:246-252. [PMID: 30460175 PMCID: PMC6212393 DOI: 10.21037/tp.2018.09.14] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The acute care model has been proposed as a framework for quality improvement in emergency care to improve care delivery and patient flow. There is currently an absence of an overarching model inclusive of other relevant care settings, such as the inpatient ward or the intensive care unit (ICU), involved in the care of an acute illness episode. This gap limits our ability to optimize patient outcomes, improve flow, and reduce waste through all stages of acute illness. We propose that a unified approach to improve quality of care for acute illness may be achieved by extending the acute care model to the inpatient care setting.
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Affiliation(s)
- Matthew W Zackoff
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Srikant Iyer
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Maya Dewan
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Abstract
The health care industry is in the midst of incredible change, and unfortunately, change is not easy. The intensive care unit (ICU) plays a critical role in the overall delivery of care to patients in the hospital. Care in the ICU is expensive. One of the best ways of improving the value of care delivered in the ICU is to focus greater attention on the needs of the critical care workforce. Herein, we highlight three major areas of concern-the changing model of care delivery outside of the traditional four walls of the ICU, the need for greater diversity in the pediatric critical care workforce, and the widespread problem of professional burnout and its impact on patient care.
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Affiliation(s)
- Derek S Wheeler
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Maxwell
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Carley L Riley
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Bonafide CP, Localio AR, Sternler S, Ahumada L, Dewan M, Ely E, Keren R. Safety Huddle Intervention for Reducing Physiologic Monitor Alarms: A Hybrid Effectiveness-Implementation Cluster Randomized Trial. J Hosp Med 2018; 13:609-615. [PMID: 29489921 DOI: 10.12788/jhm.2956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Monitor alarms occur frequently but rarely warrant intervention. OBJECTIVE This study aimed to determine if a safety huddle-based intervention reduces unit-level alarm rates or alarm rates of individual patients whose alarms are discussed, as well as evaluate implementation outcomes. DESIGN Unit-level, cluster randomized, hybrid effectiveness-implementation trial with a secondary patient-level analysis. SETTING Children's hospital. PATIENTS Unit-level: all patients hospitalized on 4 control (n = 4177) and 4 intervention (n = 7131) units between June 15, 2015 and May 8, 2016. Patient-level: 425 patients on randomly selected dates postimplementation. INTERVENTION Structured safety huddle review of alarm data from the patients on each unit with the most alarms, with a discussion of ways to reduce alarms. MEASUREMENTS Unit-level: change in unit-level alarm rates between baseline and postimplementation periods in intervention versus control units. Patient-level: change in individual patients' alarm rates between the 24 hours leading up to huddles and the 24 hours after huddles in patients who were discussed versus not discussed in huddles. RESULTS Alarm data informed 580 huddle discussions. In unit-level analysis, intervention units had 2 fewer alarms/patient-day (95% CI: 7 fewer to 6 more, P = .50) compared with control units. In patient-level analysis, patients discussed in huddles had 97 fewer alarms/patientday (95% CI: 52-138 fewer, P < .001) in the posthuddle period compared with patients not discussed in huddles. Implementation outcome analysis revealed a low intervention dose of 0.85 patients/unit/day. CONCLUSIONS Safety huddle-based alarm discussions did not influence unit-level alarm rates due to low intervention dose but were effective in reducing alarms for individual children.
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Affiliation(s)
- Christopher P Bonafide
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - A Russell Localio
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shannon Sternler
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Luis Ahumada
- Enterprise Analytics and Reporting, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Elizabeth Ely
- Department of Nursing, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ron Keren
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Herrmann LE, Tchou M, Beck J, Dewan M, Avery C, Schickedanz A, Quinonez R, Walker L. A Faculty Development Workshop for High-Value Care Education Across Clinical Settings. MedEdPORTAL 2018; 14:10745. [PMID: 30800945 PMCID: PMC6346274 DOI: 10.15766/mep_2374-8265.10745] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/28/2018] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Despite rising health care costs, trainees frequently do not receive formal high-value care (HVC) training. As medical education often occurs through informal learning, it is imperative that medical educators be prepared to teach HVC concepts across clinical settings. METHODS This workshop was created to provide frameworks for teaching HVC across four pediatric educational settings: (1) case-based conferences, (2) inpatient rounding, (3) ambulatory visits, and (4) conversations with patients and families. Frameworks were developed based on literature review, content experts' knowledge, and internal assessment and feedback. The workshop was divided into two sections: a didactic overview of HVC education and interactive small-group sessions to practice application of the Toolkit for Teaching High-Value Care. At the end of the workshop, participants completed the Prescription for High-Value Care to create a personal action plan. RESULTS This workshop has been presented at both national and local pediatric conferences. From over 89 evaluations (83% response rate), participants felt the workshop met objectives, served as a valuable use of their time, and provided useful resources. Evaluations elicited specific actions that participants gleaned from workshop content along with proposed behavior changes, such as creating HVC case-based conferences at their home institution and initiating more value-based discussions. DISCUSSION This workshop has been successfully presented in both national and local settings and has been well received by participants. The workshop is targeted for clinical educators and aims to address the gap in faculty development for HVC education.
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Affiliation(s)
- Lisa E. Herrmann
- Assistant Professor, Department of Pediatrics, University of Cincinnati College of Medicine
- Assistant Professor, Division of Pediatric Hospital Medicine, Cincinnati Children's Hospital Medical Center
| | - Michael Tchou
- Pediatric Hospital Medicine Fellow, Cincinnati Children's Hospital Medical Center
| | - Jimmy Beck
- Assistant Professor, Division of General Pediatrics and Hospital Medicine, Seattle Children's Hospital
| | - Maya Dewan
- Assistant Professor, Department of Pediatrics, University of Cincinnati College of Medicine
- Assistant Professor, Division of Pediatric Critical Care, Cincinnati Children's Hospital Medical Center
| | - Carolyn Avery
- Assistant Professor, Department of Pediatrics, Section of Medicine-Pediatrics, Duke University Medical Center
| | - Adam Schickedanz
- Clinical Instructor, Department of Pediatrics, UCLA Medical Center
| | - Ricardo Quinonez
- Associate Professor, Department of Pediatrics, Baylor College of Medicine
| | - Lauren Walker
- Associate Professor, Department of Pediatrics, Baylor College of Medicine
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Shelov E, Muthu N, Wolfe H, Traynor D, Craig N, Bonafide C, Nadkarni V, Davis D, Dewan M. Design and Implementation of a Pediatric ICU Acuity Scoring Tool as Clinical Decision Support. Appl Clin Inform 2018; 9:576-587. [PMID: 30068013 DOI: 10.1055/s-0038-1667122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Pediatric in-hospital cardiac arrest most commonly occurs in the pediatric intensive care unit (PICU) and is frequently preceded by early warning signs of clinical deterioration. In this study, we describe the implementation and evaluation of criteria to identify high-risk patients from a paper-based checklist into a clinical decision support (CDS) tool in the electronic health record (EHR). MATERIALS AND METHODS The validated paper-based tool was first adapted by PICU clinicians and clinical informaticians and then integrated into clinical workflow following best practices for CDS design. A vendor-based rule engine was utilized. Littenberg's assessment framework helped guide the overall evaluation. Preliminary testing took place in EHR development environments with more rigorous evaluation, testing, and feedback completed in the live production environment. To verify data quality of the CDS rule engine, a retrospective Structured Query Language (SQL) data query was also created. As a process metric, preparedness was measured in pre- and postimplementation surveys. RESULTS The system was deployed, evaluating approximately 340 unique patients monthly across 4 clinical teams. The verification against retrospective SQL of 15-minute intervals over a 30-day period revealed no missing triggered intervals and demonstrated 99.3% concordance of positive triggers. Preparedness showed improvements across multiple domains to our a priori goal of 90%. CONCLUSION We describe the successful adaptation and implementation of a real-time CDS tool to identify PICU patients at risk of deterioration. Prospective multicenter evaluation of the tool's effectiveness on clinical outcomes is necessary before broader implementation can be recommended.
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Affiliation(s)
- Eric Shelov
- Department of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Naveen Muthu
- Department of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Heather Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Danielle Traynor
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Nancy Craig
- Department of Respiratory Therapy, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Christopher Bonafide
- Department of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Daniela Davis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Maya Dewan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States.,Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
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Rutledge C, Walsh CM, Swinger N, Auerbach M, Castro D, Dewan M, Khattab M, Rake A, Harwayne-Gidansky I, Raymond TT, Maa T, Chang TP. Gamification in Action: Theoretical and Practical Considerations for Medical Educators. Acad Med 2018; 93:1014-1020. [PMID: 29465450 DOI: 10.1097/acm.0000000000002183] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Gamification involves the application of game design elements to traditionally nongame contexts. It is increasingly being used as an adjunct to traditional teaching strategies in medical education to engage the millennial learner and enhance adult learning. The extant literature has focused on determining whether the implementation of gamification results in better learning outcomes, leading to a dearth of research examining its theoretical underpinnings within the medical education context. The authors define gamification, explore how gamification works within the medical education context using self-determination theory as an explanatory mechanism for enhanced engagement and motivation, and discuss common roadblocks and challenges to implementing gamification.Although previous gamification research has largely focused on determining whether implementation of gamification in medical education leads to better learning outcomes, the authors recommend that future research should explore how and under what conditions gamification is likely to be effective. Selective, purposeful gamification that aligns with learning goals has the potential to increase learner motivation and engagement and, ultimately, learning. In line with self-determination theory, game design elements can be used to enhance learners' feelings of relatedness, autonomy, and competence to foster learners' intrinsic motivation. Poorly applied game design elements, however, may undermine these basic psychological needs by the overjustification effect or through negative effects of competition. Educators must, therefore, clearly understand the benefits and pitfalls of gamification in curricular design, take a thoughtful approach when integrating game design elements, and consider the types of learners and overarching learning objectives.
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Affiliation(s)
- Chrystal Rutledge
- C. Rutledge is assistant professor, Department of Pediatrics, Division of Pediatric Critical Care, University of Alabama School of Medicine, and codirector, Children's of Alabama Pediatric Simulation Center, Birmingham, Alabama. C.M. Walsh is assistant professor, Department of Paediatrics, University of Toronto Faculty of Medicine, staff gastroenterologist, Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, and cross-appointed scientist, Wilson Centre for Research in Education, Toronto, Ontario, Canada. N. Swinger is assistant professor, Department of Pediatrics, Riley Children's Hospital, Indianapolis, Indiana. M. Auerbach is associate professor, Department of Pediatrics and Emergency Medicine, director of pediatric simulation, Yale Center for Medical Simulation, and associate pediatric trauma medical director, Yale University School of Medicine, New Haven, Connecticut. D. Castro is assistant professor, Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Houston, Texas. M. Dewan is assistant professor, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. M. Khattab is assistant professor, Department of Pediatrics, Baylor College of Medicine, Houston, Texas. A. Rake is clinical assistant professor, Department of Pediatrics, Keck School of Medicine of the University of Southern California, and medical director, Children's Hospital Los Angeles Simulation Center and Las Madrinas Pediatric Simulation Research Laboratory, Los Angeles, California. I. Harwayne-Gidansky is assistant professor of clinical pediatrics, Stony Brook Children's Hospital, Stony Brook, New York. T.T. Raymond is professor, Department of Pediatrics, Division of Cardiac Critical Care, Medical City Children's Hospital, Dallas, Texas. T. Maa is assistant clinical professor, Department of Pediatrics, Ohio State University College of Medicine, and medical director, In Situ Simulation Program, Nationwide Children's Hospital, Columbus, Ohio. T.P. Chang is associate professor of clinical pediatrics, Keck School of Medicine of the University of Southern California and Children's Hospital Los Angeles, Los Angeles, California
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Affiliation(s)
| | - Maya Dewan
- Critical Care, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Heneghan M, Hart J, Dewan M, Wu K, Hope K, Taylor A, Shaw K, Bamat T. No Cause for Alarm: Decreasing Inappropriate Pulse Oximetry Use in Bronchiolitis. Hosp Pediatr 2018; 8:hpeds.2017-0126. [PMID: 29382688 DOI: 10.1542/hpeds.2017-0126] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Mallorie Heneghan
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Jessica Hart
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Katherine Wu
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Kyle Hope
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - April Taylor
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Kathy Shaw
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Tara Bamat
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
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Dewan M, Galvez J, Polsky T, Kreher G, Kraus B, Ahumada L, Mccloskey J, Wolfe H. Reducing Unnecessary Postoperative Complete Blood Count Testing in the Pediatric Intensive Care Unit. Perm J 2017; 21:16-051. [PMID: 28241909 DOI: 10.7812/tpp/16-051] [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] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Complete blood count (CBC) testing commonly occurs to determine the need for blood transfusions after surgical procedures. Many clinicians believe postoperative CBCs are "routine." OBJECTIVE To decrease unnecessary routine CBC testing in a low-risk cohort of postoperative patients in the pediatric intensive care unit (PICU) at The Children's Hospital of Philadelphia by 50% in 6 months. DESIGN Quality-improvement study. Data from our institution regarding frequency of ordering laboratory studies and transfusion requirements were collected for prior quality-improvement work demonstrating the safety and feasibility of avoiding routine postoperative CBCs in this cohort. Baseline survey data were gathered from key stakeholders on attitudes about and utilization of routine postoperative laboratory testing. Patient and clinician data were shared with all PICU clinicians. Simple Plan-Do-Study-Act cycles involving education, audit, and feedback were put into place. MAIN OUTCOME MEASURES Percentage of postoperative patients receiving CBCs within 48 hours of PICU admission. Balancing measures were hemoglobin level below 8 g/dL in patients for whom CBCs were sent and blood transfusions up to 7 days postoperatively for any patients in this cohort. RESULTS Sustained decreases below our 50% goal were seen after our interventions. There were no hemoglobin results below 8 g/dL or surgery-related blood transfusions in this cohort within 7 days of surgery. Estimated hospital charges related to routine postoperative CBCs decreased by 87% during 6 postintervention months. CONCLUSION A simple approach to a systemic problem in the PICU of unnecessary laboratory testing is feasible and effective. By using local historical data, we were able to identify a cohort of patients for whom routine postoperative CBC testing is unnecessary.
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Affiliation(s)
- Maya Dewan
- Instructor in the Division of Critical Care Medicine at the Cincinnati Children's Hospital Medical Center in OH.
| | - Jorge Galvez
- Assistant Professor of Anesthesia and Critical Care at The Children's Hospital of Philadelphia in PA.
| | - Tracey Polsky
- Assistant Director of the Clinical Chemistry Laboratory and an Assistant Professor in the Department of Pathology and Laboratory Medicine at The Children's Hospital of Philadelphia in PA.
| | - Genna Kreher
- Healthcare Data Analyst in the Office of Quality and Safety at The Children's Hospital of Philadelphia in PA.
| | - Blair Kraus
- Improvement Advisor in the Office of Quality and Safety at the The Children's Hospital of Philadelphia in PA.
| | - Luis Ahumada
- Information Scientist in the Department of Anesthesia and Critical Care at The Children's Hospital of Philadelphia in PA.
| | - John Mccloskey
- Chief of the Division of Pediatric Anesthesia and Critical Care Medicine at the Johns Hopkins University Hospital in Baltimore, MD.
| | - Heather Wolfe
- Assistant Professor of Anesthesia and Critical Care at The Children's Hospital of Philadelphia in PA.
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Dewan M, Wolfe H, Lin R, Ware E, Weiss M, Song L, MacMurchy M, Davis D, Bonafide C. Impact of a Safety Huddle-Based Intervention on Monitor Alarm Rates in Low-Acuity Pediatric Intensive Care Unit Patients. J Hosp Med 2017; 12:652-657. [PMID: 28786432 DOI: 10.12788/jhm.2782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Physiologic monitors generate high rates of alarms in the pediatric intensive care unit (PICU), yet few are actionable. OBJECTIVE To determine the association between a huddle-based intervention focused on reducing unnecessary alarms and the change in individual patients' alarm rates in the 24 hours after huddles. DESIGN Quasi-experimental study with concurrent and historical controls. SETTING A 55-bed PICU. PARTICIPANTS Three hundred low-acuity patients with more than 40 alarms during the 4 hours preceding a safety huddle in the PICU between April 1, 2015, and October 31, 2015. INTERVENTION Structured safety huddle review and discussion of alarm causes and possible monitor parameter adjustments to reduce unnecessary alarms. MAIN MEASUREMENTS Rate of priority alarms per 24 hours occurring for intervention patients as compared with concurrent and historical controls. Balancing measures included unexpected changes in patient acuity and code blue events. RESULTS Clinicians adjusted alarm parameters in the 5 hours following the huddles in 42% of intervention patients compared with 24% of control patients (𝑃 = .002). The estimate of the effect of the intervention adjusted for age and sex compared with concurrent controls was a reduction of 116 priority alarms (95% confidence interval, 37-194) per 24 hours (𝑃 = .004). There were no unexpected changes in patient acuity or code blue events related to the intervention. CONCLUSIONS Integrating a data-driven monitor alarm discussion into safety huddles was a safe and effective approach to reducing alarms in low-acuity, highalarm PICU patients.
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Affiliation(s)
- Maya Dewan
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Heather Wolfe
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Richard Lin
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eileen Ware
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michelle Weiss
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lihai Song
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew MacMurchy
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Daniela Davis
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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