OBJECTIVES:To define and reduce the incidence of severe arterial catheter-associated proximal ischemic injuries (ACAPII). DESIGN:Quality improvement (QI) initiative. SETTING:University affiliated PICU in a quaternary children's hospital. PATIENTS:All patients with indwelling arterial catheters (ACs) in the PICU at the Children's Hospital of Philadelphia from January 2020 to December 2022. INTERVENTIONS:Phase I (January 2021 to December 2021) included defining ACAPII and daily rounding on all ACs by a dedicated PICU-specific vascular access team. Phase II (January 2022 to December 2022) introduced standardized recommendations and interventions including the use of topical nitroglycerin ointment (TNG) as a therapeutic option for mild injuries. MEASUREMENTS AND MAIN RESULTS:From January 2021 to December 2022, the rounding team evaluated 1916 ACs for a total of 5793 rounding episodes (line-days). During phase I, the overall number of ACAPII increased compared with prior year pre-QI (35 vs. 11, 318%). During phase II, the administration of TNG was associated with an increase in arterial line-days per AC in patients with mild injury (6.58 line-days per line, 158 d/24 lines) compared with pre-QI, phase I, and phase II mild injuries without use of TNG (3.27, 198/61; incident rate difference [95% CI], 3.31 [2.11-4.51]; p < 0.001). Special cause indicators shifted centerline from a weighted average 33.0-342.3 line-days between severe injuries. The cumulative severe ACAPII incidence rate decreased from its peak early in phase I (April 2021: 5.65 per 1000 line-days) to the end of phase II (December 2022: 2.11 per 1000 line-days). The overall rate of arterial line-days per AC during phase II increased compared with pre-QI ( p < 0.01) and phase I ( p < 0.01). CONCLUSIONS:The development of a newly defined measurable harm index, ACAPII, and implementation of increased surveillance resulted in increased awareness and reduction of severe injury as measured by rates and line-days between severe injuries in our critically ill patients. Protocolized management during phase II, including introducing TNG as a therapeutic option, resulted in increased AC line-days per catheter with sustained reduction in severe ACAPII rates.

OBJECTIVES:The primary objective was to determine the prevalence and characteristics associated with malpositioned temporary, nontunneled central venous catheters (CVCs) placed via the internal jugular (IJ) and subclavian (SC) veins in pediatric patients. DESIGN:Single-center retrospective cohort study. SETTING:Quaternary academic PICU. PATIENTS:Children greater than 1 month to less than 18 years who had a CVC placed between January 2014 and December 2018. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:The primary outcome was the CVC tip position located on the first postprocedural radiograph. CVC tip was defined as follows: "recommended" (tip location between the carina and two vertebral bodies inferior to the carina), "high" (tip location between one and four vertebral bodies superior to the carina), "low" (tip position three or more vertebral bodies inferior to the carina), and "other" (tip grossly malpositioned). Seven hundred eighty-one CVCs were included: 481 (61.6%) were in "recommended" position, 157 (20.1%) were "high," 131 (16.8%) were "low," and 12 (1.5%) were "other." Multiple multinomial regression (referenced to "recommended" position) showed that left-sided catheters (adjusted odds ratio [aOR], 2.00, 95% CI 1.17-3.40) were associated with "high" CVC tip positions, whereas weight greater than or equal to 40 kg had decreased odds of having a "high" CVC tip compared with the reference (aOR, 0.45; 95% CI, 0.24-0.83). Further, weight category 20-40 kg (aOR, 2.42; 95% CI, 1.38-4.23) and females (aOR, 1.51; 95% CI, 1.01-2.26) were associated with "low" CVC tip positions. There was no difference in rates of central line-associated blood stream infection, venous thromboembolism, or tissue plasminogen activator usage or dose between the CVCs with tips outside and those within the recommended location. CONCLUSIONS:The prevalence of IJ and SC CVC tips outside of the recommended location was high. Left-sided catheters, patient weight, and sex were associated with malposition. Malpositioned catheters were not associated with increased harm.

Early in the coronavirus disease 2019 (COVID-19) pandemic, the CDC recommended collection of a lower respiratory tract (LRT) specimen for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) testing in addition to the routinely recommended upper respiratory tract (URT) testing in mechanically ventilated patients. Significant operational challenges were noted at our institution using this approach. In this report, we describe our experience with routine collection of paired URT and LRT sample testing. Our results revealed a high concordance between the 2 sources, and that all children tested for SARS-CoV-2 were appropriately diagnosed with URT testing alone. There was no added benefit to LRT testing. Based on these findings, our institutional approach was therefore adjusted to sample the URT alone for most patients, with LRT sampling reserved for patients with ongoing clinical suspicion for SARS-CoV-2 after a negative URT test.

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.

Weber, Mark1; Conlon, Thomas2; Woods-Hill, Charlotte3; Crowe, Rachael2; Watts, Stephanie2; Glau, Christie2; Davis, Daniela2; Himebauch, Adam3 Author Information

BACKGROUND Brain injury with changes in clinical neurological signs and symptoms can develop while children are undergoing treatment in the intensive care unit. Critical care nurses routinely screen for neurological decline by using serial bedside neurological assessments. However, assessment components, frequency, and communication thresholds are not standardized. OBJECTIVES To standardize neurological assessment procedures used by nurses, improve compliance with physicians' ordering and nurses' documentation of neurological assessments, and explore the frequency with which changes from preillness neurological status and previous assessments can be detected by using the assessment tool developed. METHODS A quality improvement intervention was implemented during a 1-year period in a 55-bed pediatric intensive care unit with 274 nurses. Procedures for neurological assessment by nurses were standardized, a system for physicians to order neurological assessments by nurses at a frequency based on the patient's risk for brain injury was developed and implemented, and a system to compare patients' current neurological status with their preillness neurological status was developed and implemented. RESULTS Process metrics that focused on compliance of ordering and documenting the standardized neurological assessments indicated improvement and sustained compliance greater than 80%. Exploratory analyses indicated that 29% of patients had an episode of neurological decline and that these episodes were more common in patients with developmental disabilities than in patients without such disabilities. CONCLUSIONS Compliance with physicians' ordering and nurses' documentation of standardized neurological assessments significantly increased and had excellent sustainability. Further work is needed to determine the sensitivity of standardized nurses' neurological assessment tools for clinically meaningful neurological decline.

OBJECTIVES:To evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation.DESIGN:Prospective pre/post observational study.SETTING:A large single-center noncardiac PICU in North America.PATIENTS:All patients less than 18 years old who underwent primary tracheal intubation from August 1, 2014, to September 30, 2018.INTERVENTIONS:Implementation of apneic oxygenation for all primary tracheal intubation as quality improvement.MEASUREMENTS AND MAIN RESULTS:Total of 1,373 tracheal intubations (661 preimplementation and 712 postimplementation) took place during study period. Within 2 months, apneic oxygenation use reached to predefined adherence threshold (> 80% of primary tracheal intubations) after implementation and sustained at greater than 70% level throughout the postimplementation. Between the preimplementation and postimplementation, no significant differences were observed in patient demographics, difficult airway features, or providers. Respiratory and procedural indications were more common during preintervention. Video laryngoscopy devices were used more often during the postimplementation (pre 5% vs post 75%; p < 0.001). Moderate oxygen desaturation less than 80% were observed in fewer tracheal intubations after apneic oxygenation implementation (pre 15.4% vs post 11.8%; p = 0.049); severe oxygen desaturation less than 70% was also observed in fewer tracheal intubations after implementation (pre 10.4% vs post 7.2%; p = 0.032). Hemodynamic tracheal intubation associated events (i.e., cardiac arrests, hypotension, dysrhythmia) were unchanged (pre 3.2% vs post 2.0%; p = 0.155). Multivariable analyses showed apneic oxygenation implementation was significantly associated with a decrease in moderate desaturation less than 80% (adjusted odds ratio, 0.55; 95% CI, 0.34-0.88) and with severe desaturation less than 70% (adjusted odds ratio, 0.54; 95% CI, 0.31-0.96) while adjusting for tracheal intubation indications and device.CONCLUSIONS:Implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. Use of apneic oxygenation should be considered when intubating critically ill children.

Objectives: To create a bedside peripherally inserted central catheter service to increase placement of bedside peripherally inserted central catheter in PICU patients. Design: Two-phase observational, pre-post design. Setting: Single-center quaternary noncardiac PICU. Patients: All patients admitted to the PICU. Interventions: From June 1, 2015, to May 31, 2017, a bedside peripherally inserted central catheter service team was created (phase I) and expanded (phase II) as part of a quality improvement initiative. A multidisciplinary team developed a PICU peripherally inserted central catheter evaluation tool to identify amenable patients and to suggest location and provider for procedure performance. Outcome, process, and balancing metrics were evaluated. Measurements and Main Results: Bedside peripherally inserted central catheter service placed 130 of 493 peripherally inserted central catheter (26%) resulting in 2,447 hospital central catheter days. A shift in bedside peripherally inserted central catheter centerline proportion occurred during both phases. Median time from order to catheter placement was reduced for peripherally inserted central catheters placed by bedside peripherally inserted central catheter service compared with placement in interventional radiology (6 hr [interquartile range, 2-23 hr] vs 34 hr [interquartile range, 19-61 hr]; p < 0.001). Successful access was achieved by bedside peripherally inserted central catheter service providers in 96% of patients with central tip position in 97%. Bedside peripherally inserted central catheter service central line-associated bloodstream infection and venous thromboembolism rates were similar to rates for peripherally inserted central catheters placed in interventional radiology (all central line-associated bloodstream infection, 1.23 vs 2.18; p = 0.37 and venous thromboembolism, 1.63 vs 1.57; p = 0.91). Peripherally inserted central catheters in PICU patients had reduced in-hospital venous thromboembolism rate compared with PICU temporary catheter in PICU rate (1.59 vs 5.36; p < 0.001). Conclusions: Bedside peripherally inserted central catheter service implementation increased bedside peripherally inserted central catheter placement and employed a patient-centered and timely process. Balancing metrics including central line-associated bloodstream infection and venous thromboembolism rates were not significantly different between peripherally inserted central catheters placed by bedside peripherally inserted central catheter service and those placed in interventional radiology.

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.

Woods-Hill, Charlotte; Papili, Kelly; Nelson, Eileen; Watts, Stephanie; Quinn, Deanna; Davis, Daniela; Priestley, Margaret Author Information

Purpose Prior to our intervention, there was no systematic method to identify Hotspots (patients at high risk for clinical deterioration and code bell activation) and prepare the bedside for code bell activation in our ICU. Hotspot identification previously relied upon provider intuition reported at daily safety huddles, without a standardized physiology, lab or evidence informed approach leading to significant variability among clinicians. Our primary objectives was to improve prediction of Hotspots to 70% and improve bedside preparedness for clinical …

BACKGROUNDPhysiologic monitors generate high rates of alarms in the pediatric intensive care unit (PICU), yet few are actionable.OBJECTIVETo 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.DESIGNQuasi‐experimental study with concurrent and historical controls.SETTINGA 55‐bed PICU.PARTICIPANTSThree 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.INTERVENTIONStructured safety huddle review and discussion of alarm causes and possible monitor parameter adjustments to reduce unnecessary alarms.MAIN MEASUREMENTSRate 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.RESULTSClinicians 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.CONCLUSIONIntegrating a data‐driven monitor alarm discussion into safety huddles was a safe and effective approach to reducing alarms in low‐acuity, high‐alarm PICU patients.

Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) January and November 2014, in an academic tertiary care center. The RRT activation symptoms, sign and markers were collected in real time. The triage decision for RRT evaluation was recorded. Multinomial logistic regression was employed to identify the adjusted odds ratio for ICU admission per each activation trigger. Results: During the study period, we performed 1,229 calls for 944 unique patients. The following activation triggers were found to be positive or negative predictors of ICU admission. Surgical vs. medical service (Odds Ratio [OR] 1.66, Standard Error [SE] 0.33, P<0.01), hypotension (OR 1.93, SE 0.38, P<0.001), chest pain (OR 0.42, SE 0.12, P<0.01), respiratory distress (OR 2.67, SE 0.94, P<0.01), tachypnea (OR 1.95, 0.36, P<0.001), dyspnea (OR 2.12, SE 0.44, P<0.001), decreased oxygen saturation (OR 2.0, SE 0.35, P<0.001), change in mental status (OR 1.84, SE 0.37, P <0.01), airway bleeding (OR 5.51, SE 4.54, P=0.03) uncontrolled bleeding (OR 4.24, SE 2.01, P<0.01) problems with IV access (OR 1.96, SE 0.39, P<0.001). Conclusions: Our study suggests that some clinical triggers are more powerful than others in predicting ICU admission. Further understanding on which rapid response triggers are associated with ICU admission, may help in the design of improved prediction algorithms and further facilitate prompt triage and inpatient rescue efforts.

Abstract Accurate medication reconciliation at the time of hospital admission is vital to preventing adverse drug events. Compliance with medication reconciliation in our pediatric intensive care unit was low initially with overall medication reconciliation at 70%. Due to the high front line provider turnover in our unit, we focused on technological reminders for completion and used unique and innovative ways to motivate our supervising staff. Our goal was to reach >95% completion within 24 hours for medication reconciliation for all patients admitted to the pediatric intensive care unit. Pre-pilot discussions focused on examples of errors of medication reconciliation within our own institution resulting in patient harm via traditional power point presentation. The initial pilot phase instituted a job aid on how to add the medication reconciliation completion reminder column. Email updates on completion status began one week after initiation. During the implementation and spread phase, fun interactive videos were used to acknowledge roll out to the full unit. Compliance was monitored and humorous biweekly video updates emphasizing accountability were introduced. In the sustain phase, monthly video updates served as education and a reminder for provider staff. The use of a medication reconciliation completion column and reminder emails resulted in goal completion (>95%) by three weeks post intervention for the pilot unit. Overall medication reconciliation completion also reached goal of >95% completion within the entire unit after three weeks of implementation and spread. Compliance fell below goal so video updates were modified utilizing humor and emphasizing accountability. This resulted in sustained compliance now more than forty weeks post implementation. Unit compliance currently remains >95% completion within 24 hours now more than forty weeks post intervention. The use of the medication reconciliation reminder column resulted in improvement in compliance; however, that improvement was not sustained. The addition of humorous videos highlighting accountability allowed for sustained improvements.

Variables affecting duration of pediatric extracorporeal life support (ECLS) are poorly defined. Prior analyses suggested increased mortality risk with prolonged ECLS. Lung recruitment strategies with improved secretion mobilization may shorten ECLS duration. High frequency percussive ventilation (HFPV) has been used, predominantly in inhalational injury, as a mode of ventilation to improve secretion clearance. We describe the application of HFPV and therapeutic bronchoscopies in pediatric ECLS and evaluate outcomes with a same-center historical control population. After May 2011, all children (n = 14) on ECLS were managed with HFPV during extracorporeal support (HFPV cohort). This group’s demographics and outcomes were compared with ECLS patients in our unit immediately before the utilization of HFPV (pre-HFPV cohort, n = 22). The HFPV and pre-HFPV cohorts had similar demographics and utilization of venoarterial ECLS. In univariate analysis, the HFPV group underwent more bronchoscopies and experienced more ECLS-free days (days alive and off ECLS) at 30 and 60 days. In multivariate analysis, use of HFPV was independently associated with ECLS-free days. We conclude that use of HFPV and bronchoscopies during ECLS for respiratory failure was associated with an increase in ECLS-free days and that this association should be prospectively evaluated.

Objective: In-hospital cardiac arrest is an important public health problem. High-quality resuscitation improves survival but is difficult to achieve. Our objective is to evaluate the effectiveness of a novel, interdisciplinary, postevent quantitative debriefing program to improve survival outcomes after in-hospital pediatric chest compression events.Design, Setting, and Patients: Single-center prospective interventional study of children who received chest compressions between December 2008 and June 2012 in the ICU.Interventions: Structured, quantitative, audiovisual, interdisciplinary debriefing of chest compression events with front-line providers.Measurements and Main Results: Primary outcome was survival to hospital discharge. Secondary outcomes included survival of event (return of spontaneous circulation for 20 min) and favorable neurologic outcome. Primary resuscitation quality outcome was a composite variable, termed excellent cardiopulmonary resuscitation, prospectively defined as a chest compression depth 38 mm, rate 100/min, 10% of chest compressions with leaning, and a chest compression fraction > 90% during a given 30-second epoch. Quantitative data were available only for patients who are 8 years old or older. There were 119 chest compression events (60 control and 59 interventional). The intervention was associated with a trend toward improved survival to hospital discharge on both univariate analysis (52% vs 33%, p = 0.054) and after controlling for confounders (adjusted odds ratio, 2.5; 95% CI, 0.91-6.8; p = 0.075), and it significantly increased survival with favorable neurologic outcome on both univariate (50% vs 29%, p = 0.036) and multivariable analyses (adjusted odds ratio, 2.75; 95% CI, 1.01-7.5; p = 0.047). Cardiopulmonary resuscitation epochs for patients who are 8 years old or older during the debriefing period were 5.6 times more likely to meet targets of excellent cardiopulmonary resuscitation (95% CI, 2.9-10.6; p < 0.01).Conclusion: Implementation of an interdisciplinary, postevent quantitative debriefing program was significantly associated with improved cardiopulmonary resuscitation quality and survival with favorable neurologic outcome.

The importance of preventing venous thromboembolism (VTE) in hospitalized adults is well recognized. We recently developed and published our institutional guidelines for the prevention of VTE in high-risk hospitalized patients in a pediatric hospital. The objective of this prospective observational study was to evaluate the safety of anticoagulation after these guidelines were instituted. The primary outcome was major bleeding and secondary outcomes included minor bleeding and VTE. Eighty-nine patients were enrolled, with a mean age of 16.6 years. The most common risk factors for VTE were impaired mobility, lower extremity orthopedic surgery, and obesity. The majority of patients (63%) had 3 or more risk factors. There were 2 major bleeding events, and minor bleeding occurred in 5 patients, all in patients who had undergone major orthopedic surgery. Therefore the risk of major bleeding in orthopedic surgery patients was 4% (2/51), and 0% (0/38) in the remaining patients. No patient developed a non-catheter-related VTE, which was the primary intent of our guidelines. Although there remains much work to be done to optimize VTE strategies in pediatric patients, this study provides information regarding the risks of VTE prophylaxis using a pragmatic approach in hospitalized patients with multiple risk factors for VTE. More studies are needed to better define the risk:benefit ratio in this population.