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Fundora MP, Kalicheti M, Zhao G, Maher KO, Serban N. Opioid Utilization after Cardiac Surgery in the Pediatric Medicaid-Insured Population. J Pediatr 2024; 265:113809. [PMID: 37918516 DOI: 10.1016/j.jpeds.2023.113809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/25/2023] [Accepted: 10/29/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE To determine the variation of outpatient opioid prescribing across the US in postoperative pediatric cardiac patients. STUDY DESIGN Retrospective, cross-sectional study using a concatenated database of Medicaid claims between from 2016 through 2018 of children 0-17 years, discharged after cardiac surgery and receiving an opioid prescription within 30 days. Filled prescriptions were identified and converted to morphine milligram equivalents (MME). Use, duration, and dose were analyzed by sex, race, ethnicity, residence urbanicity, and region. RESULTS Among 17 186 Medicaid-enrolled children after cardiac surgery, 2129 received opioids within 30 days of discharge. Females received lower doses than males (coefficient -0.17, P = .022). Hispanic individuals were less likely to receive opioids (coefficient 0.53, P < .05, 95% CI: 0.38-0.71) and for shorter periods (coefficient 0.83, P < .001). Midwest (MW) (OR 0.61, 95% P-values < 0.05, 95% CI: 0.46-0.80) and Northeast (NE) (OR 0.43, 95% P-values < 0.05, 95% CI: 0.30-0.61) regions were less likely to receive opioids but used higher doses compared with the Southeast (SE) (MW coefficient 0.41, Southwest (SW) coefficient 0.18, NE coefficient 0.32, West (W) coefficient 0.19, P < .05). CONCLUSIONS There were significant variations in opioid prescribing after cardiac surgery by race, ethnicity, sex, and region. National guidelines for outpatient use of opioids in children after cardiac surgery may help limit practice variation and reduce potential harms in outpatient opioid usage.
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Affiliation(s)
- Michael P Fundora
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA.
| | - Manvitha Kalicheti
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Guantao Zhao
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
| | - Kevin O Maher
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Nicoleta Serban
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA
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Hillyer MM, Jaggi P, Chanani NK, Fernandez AJ, Zaki H, Fundora MP. Antimicrobial Stewardship and Improved Antibiotic Utilization in the Pediatric Cardiac Intensive Care Unit. Pediatr Qual Saf 2024; 9:e710. [PMID: 38322295 PMCID: PMC10843537 DOI: 10.1097/pq9.0000000000000710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/22/2023] [Indexed: 02/08/2024] Open
Abstract
Background We developed a multidisciplinary antimicrobial stewardship team to optimize antimicrobial use within the Pediatric Cardiac Intensive Care Unit. A quality improvement initiative was conducted to decrease unnecessary broad-spectrum antibiotic use by 20%, with sustained change over 12 months. Methods We conducted this quality improvement initiative within a quaternary care center. PDSA cycles focused on antibiotic overuse, provider education, and practice standardization. The primary outcome measure was days of therapy (DOT)/1000 patient days. Process measures included electronic medical record order-set use. Balancing measures focused on alternative antibiotic use, overall mortality, and sepsis-related mortality. Data were analyzed using statistical process control charts. Results A significant and sustained decrease in DOT was observed for vancomycin and meropenem. Vancomycin use decreased from a baseline of 198 DOT to 137 DOT, a 31% reduction. Meropenem use decreased from 103 DOT to 34 DOT, a 67% reduction. These changes were sustained over 24 months. The collective use of gram-negative antibiotics, including meropenem, cefepime, and piperacillin-tazobactam, decreased from a baseline of 323 DOT to 239 DOT, a reduction of 26%. There was no reciprocal increase in cefepime or piperacillin-tazobactam use. Key interventions involved electronic medical record changes, including automatic stop times and empiric antibiotic standardization. All-cause mortality remained unchanged. Conclusions The initiation of a dedicated antimicrobial stewardship initiative resulted in a sustained reduction in meropenem and vancomycin usage. Interventions did not lead to increased utilization of alternative broad-spectrum antimicrobials or increased mortality. Future interventions will target additional broad-spectrum antimicrobials.
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Affiliation(s)
- Margot M. Hillyer
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine
| | - Preeti Jaggi
- Division of Infectious Disease, Department of Pediatrics, Emory University School of Medicine
| | - Nikhil K. Chanani
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine
| | | | - Hania Zaki
- Department of Pharmacy, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Michael P. Fundora
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine
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Wright BN, Glidewell MJ, Downing KF, Vagi KJ, Fundora MP, Farr SL. Bullying among children with heart conditions, National Survey of Children's Health, 2018-2020. Cardiol Young 2023:1-9. [PMID: 38111963 DOI: 10.1017/s1047951123004225] [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: 12/20/2023]
Abstract
Children with chronic illnesses report being bullied by peers, yet little is known about bullying among children with heart conditions. Using 2018-2020 National Survey of Children's Health data, the prevalence and frequency of being bullied in the past year (never; annually or monthly; weekly or daily) were compared between children aged 6-17 years with and without heart conditions. Among children with heart conditions, associations between demographic and health characteristics and being bullied, and prevalence of diagnosed anxiety or depression by bullying status were examined. Differences were assessed with chi-square tests and multivariable logistic regression using predicted marginals to produce adjusted prevalence ratios and 95% confidence intervals. Weights yielded national estimates. Of 69,428 children, 2.2% had heart conditions. Children with heart conditions, compared to those without, were more likely to be bullied (56.3% and 43.3% respectively; adjusted prevalence ratio [95% confidence interval] = 1.3 [1.2, 1.4]) and bullied more frequently (weekly or daily = 11.2% and 5.3%; p < 0.001). Among children with heart conditions, characteristics associated with greater odds of weekly or daily bullying included ages 9-11 years compared to 15-17 years (3.4 [2.0, 5.7]), other genetic or inherited condition (1.7 [1.0, 3.0]), ever overweight (1.7 [1.0, 2.8]), and a functional limitation (4.8 [2.7, 8.5]). Children with heart conditions who were bullied, compared to never, more commonly had anxiety (40.1%, 25.9%, and 12.8%, respectively) and depression (18.0%, 9.3%, and 4.7%; p < 0.01 for both). Findings highlight the social and psychological needs of children with heart conditions.
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Affiliation(s)
- Brittany N Wright
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA, USA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - M Jill Glidewell
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA, USA
| | - Karrie F Downing
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA, USA
| | - Kevin J Vagi
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA, USA
| | - Michael P Fundora
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA, USA
- Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, USA
| | - Sherry L Farr
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA, USA
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Fundora MP, Kamidani S, Oster ME. COVID Vaccination as a Strategy for Cardiovascular Disease Prevention. Curr Cardiol Rep 2023; 25:1327-1335. [PMID: 37688764 DOI: 10.1007/s11886-023-01950-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/11/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular (CV) disease is a known complication of SARS-CoV-2 infection. A clear benefit of COVID-19 vaccination is a reduction mortality; however, COVID-19 vaccination may also prevent cardiovascular disease (CVD). We aim to describe CV pathology associated with SARS-CoV-2 infection and describe how COVID-19 vaccination is a strategy for CVD prevention. RECENT FINDINGS The risks and benefits of COVID-19 vaccination have been widely studied. Analysis of individuals with and without pre-existing CVD has shown that COVID-19 vaccination can prevent morbidity associated with SARS-CoV-2 infection and reduce mortality. COVID-19 vaccination is effective in preventing myocardial infarction, cerebrovascular events, myopericarditis, and long COVID, all associated with CVD risk factors. Vaccination reduces mortality in patients with pre-existing CVD. Further study investigating ideal vaccination schedules for individuals with CVD should be undertaken to protect this vulnerable group and address new risks from variants of concern.
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Affiliation(s)
- Michael P Fundora
- Children's Healthcare of Atlanta Cardiology, Department of Pediatrics, Emory University, 1405 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Satoshi Kamidani
- The Center for Childhood Infections and Vaccines of Children's Healthcare of Atlanta and the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew E Oster
- Children's Healthcare of Atlanta Cardiology, Department of Pediatrics, Emory University, 1405 Clifton Rd NE, Atlanta, GA, 30322, USA.
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Truitt BA, Kasi AS, Kamat PP, Fundora MP, Simon DM, Guglani L. Cryoextraction via flexible bronchoscopy in children with tracheobronchial obstruction. Pediatr Pulmonol 2023; 58:2527-2534. [PMID: 37350368 DOI: 10.1002/ppul.26540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 05/19/2023] [Accepted: 05/26/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Cryoextraction via flexible bronchoscopy (FB) can be used to alleviate airway obstruction due to blood clots, casts, mucus, and foreign bodies. There is limited literature regarding the utility of cryoextraction to restore airway patency in critically ill children, especially on extracorporeal membrane oxygenation (ECMO). The aims of this study were to describe the clinical course and outcomes of children who underwent cryoextraction via FB. METHODS A singlecenter retrospective review of children who underwent cryoextraction via FB between 2017 and 2021 was conducted. The analyzed data included diagnoses, indications for cryoextraction, respiratory support modalities, FB and chest imaging results, and outcomes. RESULTS Eleven patients aged 3-17 years underwent a total of 33 cryoextraction sessions via FB. Patients required ECMO (n = 9) or conventional mechanical ventilation (CMV) for pneumonia, pulmonary hemorrhage, pulmonary embolism, asthma exacerbation, and cardiorespiratory failure following cardiac surgery. One patient underwent elective FB and cryoextraction for plastic bronchitis. Indications for cryoextraction included airway obstruction due to tracheobronchial thrombi (n = 8), mucus plugs (n = 1), or plastic bronchitis (n = 2). Cryoextraction via FB was performed on patients on ECMO (n = 9) and CMV (n = 2) with 6 patients requiring ≥3 cryoextraction sessions for airway obstruction. There were no complications related to cryoextraction. Patient outcomes included partial (n = 5) or complete (n = 6) restoration of airway patency with ECMO decannulation (n = 5) and death (n = 4) due to critical illness. CONCLUSIONS Cryoextraction via FB is an effective intervention that can be utilized in critically ill children with refractory tracheobronchial obstruction to restore airway patency and to facilitate liberation from ECMO.
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Affiliation(s)
- Brittany A Truitt
- Division of Pediatric Pulmonology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Ajay S Kasi
- Division of Pediatric Pulmonology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Pradip P Kamat
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Michael P Fundora
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Dawn M Simon
- Division of Pediatric Pulmonology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Lokesh Guglani
- Division of Pediatric Pulmonology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Mills M, John M, Tang R, Fundora MP, Keesari R, Kanter K, Maher K, Chai P. Mitral Valve Replacement in Infants and Children: Experience using a 15 mm Mechanical Valve. Ann Thorac Surg 2023:S0003-4975(23)00468-X. [PMID: 37150274 DOI: 10.1016/j.athoracsur.2023.04.035] [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: 11/09/2022] [Revised: 03/03/2023] [Accepted: 04/24/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Reports using a 15-mm mechanical valve for mitral valve replacement in children are limited. We review our center's operative and postoperative experience with this valve. METHODS We performed a single-center retrospective chart review identifying patients having undergone 15-mm mechanical mitral valve replacements (MMVRs) between 2009 and 2022. We analyzed short and long-term outcomes using descriptive statistics. RESULTS Fifteen patients underwent 16 MMVRs with no operative deaths. The median age and weight at the time of operation was 6.2 months (IQR 4.4-13.7), and 5.16 kg (IQR 4.5-6.9), respectively. Ten implants (66%) were placed in the supra-annular position. Median post-operative duration of intubation was 1.5 days (IQR 1.0-3.75), CICU length of stay (LOS) was 6 days (IQR 3-13.5), and overall hospital LOS was 17.0 days (IQR 12-48.5). Three patients (20%) experienced major adverse events post-operatively. Four of 13 patients discharged home (31%) required readmission within 30 days for sub/supra-therapeutic INR values. There were no surgical mortalities and there were four late mortalities (27%). Six patients underwent subsequent MMVR at a median time to second MMVR of 6.8 (IQR 3.6-8.9) years. There are 6 patients with the original 15-mm MVR at a median time of 4.7 years since placement. CONCLUSIONS We present the largest single-center cohort of patients having undergone 15-mm MMVR. Our experience is distinguished by a lower rate of major adverse events than previously reported, durability of the device, and a rapid post operative recovery time. Appropriate and consistent anticoagulation is a significant challenge in this age group.
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Affiliation(s)
- Marcos Mills
- Heart Center, Children's Healthcare of Atlanta; Division of Pediatric Cardiology, Emory University School of Medicine;.
| | - Mohan John
- Heart Center, Children's Healthcare of Atlanta. Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine
| | - Richard Tang
- Heart Center, Children's Healthcare of Atlanta. Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine
| | - Michael P Fundora
- Heart Center, Children's Healthcare of Atlanta; Division of Pediatric Cardiology, Emory University School of Medicine
| | - Rohali Keesari
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University School of Medicine
| | - Kirk Kanter
- Heart Center, Children's Healthcare of Atlanta. Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine
| | - Kevin Maher
- Heart Center, Children's Healthcare of Atlanta; Division of Pediatric Cardiology, Emory University School of Medicine
| | - Paul Chai
- Heart Center, Children's Healthcare of Atlanta. Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine
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Beshish AG, Fundora MP, Aronoff E, Rao N, Kelleman MS, Shaw FR, Maher KO, Wolf M. Prevalence, Risk Factors, and Etiology of Extubation Failure in Pediatric Patients After Cardiac Surgery. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0041-1742253] [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: 10/19/2022] Open
Abstract
AbstractIn this article, our primary objective was to investigate the prevalence and etiology of extubation failure (EF) in patients following cardiac surgery for congenital heart disease. Secondarily, we examined the association of different risk factors with EF. This was single-center retrospective study in a 27-bed cardiac intensive care unit at a quaternary children's hospital. All patients between 0 and 18 years of age who underwent congenital cardiac surgery from January 2008 to September 2019 were included. During the study period, among 8,750 surgical encounters, 257 (2.9%) failed extubation, defined as reintubation within 48 hours from extubation. EF patients were younger, smaller, more likely to have genetic syndromes, higher Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery (STAT) mortality scores, single-ventricle physiology, longer cardiopulmonary bypass (CPB) and cross-clamp (XC) times, longer mechanical ventilation (MV) duration, and higher mortality (p <0.05). In a univariate analysis, EF patients when compared to matched controls by age, gender, and STAT score, and genetic syndrome, particularly heterotaxy, were associated with increased odds of EF (p <0.05). In a multivariable logistic regression of the entire cohort, the presence of any genetic syndrome was associated with higher odds of EF (p <0.05). In a subgroup of neonates, a univariate analysis was performed and multivariable analysis was attempted, but both did not achieve statistical significance. In summary, EF after congenital cardiac surgery is associated with younger age, lower weight, single-ventricle physiology, longer CPB and XC times, longer duration of MV, and genetic syndromes. Patients failing extubation have increased morbidity and mortality. Recognition of these risk factors may provide clinicians the ability to identify patients at high risk allowing for timely intervention to limit adverse outcomes.
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Affiliation(s)
- Asaad G. Beshish
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Michael P. Fundora
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Elizabeth Aronoff
- Emory University School of Medicine, Atlanta, Georgia, United States
| | - Nikita Rao
- Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Michael S. Kelleman
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Fawwaz R. Shaw
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Kevin O. Maher
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
| | - Michael Wolf
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, United States
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Parikh KJ, Fundora MP, Sasaki N, Rossi AF, Burke RP, Sasaki J. Use of aortic arch measurements in evaluating significant arch hypoplasia in neonates with coarctation. Progress in Pediatric Cardiology 2021. [DOI: 10.1016/j.ppedcard.2021.101410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
OBJECTIVES Healthcare workload has emerged as an important metric associated with poor outcomes. To measure workload, studies have used bed occupancy as a surrogate. However, few studies have examined frontline provider (fellows, nurse practitioners, physician assistants) workload and outcomes. We hypothesize frontline provider workload, measured by bed occupancy and staffing, is associated with poor outcomes and unnecessary testing. DESIGN A retrospective single-center, time-stamped orders, ordering provider identifiers, and patient data were collected. Regression was performed to study the influence of occupancy on orders, length of stay, and mortality, controlling for age, weight, admission type, Society of Thoracic Surgery-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality score, diagnosis, number of surgeries, orders, provider staffing, attending experience, and time fixed effects. SETTING Twenty-seven bed tertiary cardiac ICU in a free-standing children's hospital. PATIENTS Patients (0-18 yr) admitted to the pediatric cardiac ICU, January 2018 to December 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 16,500 imaging and 73,113 laboratory orders among 1,468 patient admissions. Median age 6 months (12 d to 5 yr), weight 6.2 kg (3.7-16.2 kg); 840 (57.2%) surgical and 628 (42.8%) medical patients. ICU teams consisted of 16 attendings and 31 frontline providers. Mortality 4.4%, median stay 5 days (2-11 d), and median bed occupancy 89% (78-93%). Every 10% increase in bed occupancy had 7.2% increase in imaging orders per patient (p < 0.01), 3% longer laboratory turn-around time (p = 0.015), and 3 additional days (p < 0.01). Higher staffing (> 3 providers) was associated with 6% less imaging (p = 0.03) and 3% less laboratory orders (p = 0.04). The number of "busy days" (bed occupancy > 89%) was associated with longer stays (p < 0.01), and increased mortality (p < 0.01). CONCLUSIONS Increased bed occupancy and lower staffing were associated with increased mortality, length of stay, imaging orders, and laboratory turn-around time. The data demonstrate performance of the cardiac ICU system is exacerbated during high occupancy and low staffing.
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Affiliation(s)
- Michael P Fundora
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Jiayi Liu
- Goizueta Business School, Emory University, Atlanta, GA
| | - Christina Calamaro
- Children's Healthcare of Atlanta, Emory University, Nell Hodgson School of Nursing, Atlanta, GA
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Diwas Kc
- Goizueta Business School, Emory University, Atlanta, GA
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Fundora MP, Beshish AG, Rao N, Berry CM, Figueroa J, McCracken C, Maher KO. Comparison of Invasive and Oscillometric Blood Pressure Measurement in Obese and Nonobese Children. Am J Hypertens 2021; 34:619-625. [PMID: 33693473 DOI: 10.1093/ajh/hpab049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 09/01/2020] [Revised: 12/23/2020] [Accepted: 03/04/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Obesity and hypertension are public health priorities, with obesity considered to be a potential cause of hypertension. Accurate blood pressure (BP) determination is required and often obtained by automated oscillometric cuff devices. We sought to determine the correlation of oscillometric measurement in children, and if obesity was associated with worse correlation between methods than nonobese children. METHODS Retrospective matched case-controlled study of 100 obese (97-99th percentile) and 100 nonobese (25-70th percentile) children after cardiac surgery with simultaneous systolic, diastolic, and mean invasive and oscillometric measurements. Matching was 1:1 for age, sex, race, and Risk Adjustment for Congenital Heart Surgery-1 score. Intraclass correlation coefficients and Bland-Altman plots were used to determine agreement with 0.75 as threshold. RESULTS Median age was 13 years (10-15). Agreement was low for systolic (0.65 and 0.61), diastolic (0.68 and 0.61), and mean measurements (0.73 and 0.69) (obese/nonobese). Bland-Altman plots demonstrated oscillometric BP measurements underestimated systolic hypertension (oscillometric readings lower than intra-arterial). Oscillometric measurements underestimated hypotension (systolic oscillometric measurements were higher than intra-arterial). This occurred in obese and nonobese patients. Correlation of oscillometric measurements was similar for nonobese and obese patients. CONCLUSIONS In this first ever study of simultaneous BP measurement by oscillometric vs. intra-arterial in obese and nonobese children, correlation is below accepted norms. The correlation of oscillometric cuff measurements is not affected by habitus in children. There is less correlation between oscillometric measurements and intra-arterial measurements during hypertension or hypotension. Healthcare providers should be aware of the limitations of oscillometric measurements.
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Affiliation(s)
- Michael P Fundora
- Children’s Healthcare of Atlanta, Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Asaad G Beshish
- Children’s Healthcare of Atlanta, Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nikita Rao
- Children’s Healthcare of Atlanta, Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Janet Figueroa
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kevin O Maher
- Children’s Healthcare of Atlanta, Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Nguyen T, Fundora MP, Welch E, Douglas PS, Eidem BW, Campbell RM, Weiner RB, Stern KWD, Benavidez OJ, Lai WW, Sachdeva R, Lopez L. Application of the Pediatric Appropriate Use Criteria for Chest Pain. J Pediatr 2017; 185:124-128. [PMID: 28366354 DOI: 10.1016/j.jpeds.2017.02.073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 10/11/2016] [Revised: 12/28/2016] [Accepted: 02/27/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To characterize the subgroup of outpatient pediatric patients presenting with chest pain and to determine the effectiveness of published pediatric appropriate use criteria (PAUC) to detect pathology. STUDY DESIGN The Pediatric Appropriate Use of Echocardiography study evaluated the use and yield of transthoracic echocardiography (TTE) before and after PAUC release. Data were reviewed on patients ?18 years of age who underwent TTE for chest pain. Indications were classified as appropriate (A), may be appropriate (M), and rarely appropriate (R) based on PAUC ratings, and findings were normal, incidental, or abnormal. RESULTS Chest pain was the primary indication in 772 of 4562 outpatient TTE studies (17%) (median age 14 years, IQR 10-16) ordered during the study period: 458 of 772 before (59%) and 314 of 772 after (41 %) the release of PAUC with no change in appropriateness. In A indications (n?=?654), 642 (98%) were normal, 5 (1%) had incidental findings, and 7 (1%) were abnormal. A and M detected 100% of all abnormal findings (A: n?=?7; M: n?=?6; R: n?=?0), with an association between ratings and findings (P?<.001). There was no association between R rating and any pathology. CONCLUSIONS There was no change in ordering patterns with publication of the PAUC. Despite the high rate of TTEs ordered for indications rated A, most studies were normal. Studies that detected pathology were performed for indications rated A or M, but not R. This study supports PAUC as a useful tool in pediatric chest pain evaluation that may subsequently improve the use of TTE.
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Affiliation(s)
| | | | | | | | | | - Robert M Campbell
- Emory University School of Medicine, Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, GA
| | | | | | | | - Wyman W Lai
- Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY
| | - Ritu Sachdeva
- Emory University School of Medicine, Children's Healthcare of Atlanta Sibley Heart Center Cardiology, Atlanta, GA
| | - Leo Lopez
- Nicklaus Children's Hospital, Miami, FL
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Fundora MP, Aregullin EO, Wernovsky G, Welch EM, Muniz JC, Sasaki N, Hannan RL, Burke RP, Lopez L. Echocardiographic and Surgical Correlation of Coronary Artery Patterns in Transposition of the Great Arteries. CONGENIT HEART DIS 2016; 11:570-577. [PMID: 26931510 DOI: 10.1111/chd.12338] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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] [Accepted: 01/10/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Determine the accuracy of echocardiography to diagnose coronary anatomy in transposition of the great arteries and to evaluate the effect of accuracy on surgical outcomes and changes in accuracy over time. DESIGN Retrospective chart review of neonates admitted February 1999 to March 2013 with transposition. Coronary pattern from the preoperative echocardiogram and operative reports were collected and compared with determine diagnostic accuracy. Coronary patterns were further confirmed by intraoperative images taken during surgery. SETTING Tertiary care children's hospital. PATIENTS Neonates with transposition of the great arteries and planned arterial switch operation with an echo and operative report or image describing the coronaries. INTERVENTIONS Not applicable. OUTCOME MEASURES Accuracy of echocardiography to diagnose coronary anatomy in transposition, and to identify factors related to correct diagnosis. RESULTS One hundred forty-two patients met inclusion criteria with 122 correctly diagnosed, 16 incorrect, and 4 inconclusive. Accuracy was 86%, with 95% accuracy in patients with typical coronary patterns, 85% with the most common variant (left coronary from the leftward sinus and right and circumflex from the rightward sinus), and 61% with less common patterns. Typical and common variants were more likely to be correct than atypical patterns (P < .001). Cases with ventricular septal defect were more likely to have correctly diagnosed coronaries than with an intact ventricular septum (94% vs. 79%, P = .01). There was no change in accuracy over time (P > .05). There was no difference in duration of cardiopulmonary bypass, cross-clamp times, length of stay, or postoperative stay between the correct and incorrectly diagnosed groups (P > .05). CONCLUSIONS In our center, accuracy of echocardiographic imaging of the coronary arteries in transposition was 86% without improvement over time, and perioperative outcomes were not affected by diagnostic accuracy. Further invasive imaging may not be necessary to determine the coronary pattern in this lesion.
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Affiliation(s)
- Michael P Fundora
- Department of Pediatric Cardiology, Nicklaus Children's Hospital, Miami Children's Health System, Florida International University, Herbert Wertheim College of Medicine, Miami, Fla, USA
| | - Enrique Oliver Aregullin
- Department of Pediatric Cardiology, Nicklaus Children's Hospital, Miami Children's Health System, Florida International University, Herbert Wertheim College of Medicine, Miami, Fla, USA
| | - Gil Wernovsky
- Department of Pediatric Cardiology, Nicklaus Children's Hospital, Miami Children's Health System, Florida International University, Herbert Wertheim College of Medicine, Miami, Fla, USA
| | - Elizabeth M Welch
- Department of Pediatric Cardiology, Nicklaus Children's Hospital, Miami Children's Health System, Florida International University, Herbert Wertheim College of Medicine, Miami, Fla, USA
| | - Juan-Carlos Muniz
- Department of Pediatric Cardiology, Nicklaus Children's Hospital, Miami Children's Health System, Florida International University, Herbert Wertheim College of Medicine, Miami, Fla, USA
| | - Nao Sasaki
- Department of Pediatric Cardiology, Nicklaus Children's Hospital, Miami Children's Health System, Florida International University, Herbert Wertheim College of Medicine, Miami, Fla, USA
| | - Robert L Hannan
- Department of Cardiovascular Surgery, Nicklaus Children's Hospital, Miami Children's Health System, Florida International University, Herbert Wertheim College of Medicine, Miami, Fla, USA
| | - Redmond P Burke
- Department of Cardiovascular Surgery, Nicklaus Children's Hospital, Miami Children's Health System, Florida International University, Herbert Wertheim College of Medicine, Miami, Fla, USA
| | - Leo Lopez
- Department of Pediatric Cardiology, Nicklaus Children's Hospital, Miami Children's Health System, Florida International University, Herbert Wertheim College of Medicine, Miami, Fla, USA
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