Aarti Bavare

Implementation of a Standard Verbal Sign-Out Template Improves Sign-Out Process in a Pediatric Intensive Care Unit.

Abstract: Sign-out of patient data at change of shifts is vulnerable to errors that impact patient safety. Although sign-outs are complex in intensive care units (ICU), a paucity of studies exists evaluating optimal ICU sign-out. Our prospective interventional study investigated the use of a standard verbal template in a Pediatric ICU to improve the sign-out process. We designed and validated a survey tool to measure 10 items of optimal sign-out. The survey and analysis of sign-out information exchanged was performed pre- and postintervention. Forty-eight clinicians participated, with a survey response rate of 88% and 81% in the pre- and postintervention phases, respectively. Seventy-nine percent clinicians identified the need for sign-out improvement. Clinician satisfaction with sign-out increased postintervention (preintervention survey scores: 3.26 (CI: 3.09–3.43), postintervention 3.9 (CI: 3.76–4.04) [p < .01]). Three scorers analyzed the verbal and written sign-out content with good inter-rater reliability. After the intervention, sign-out content revealed increased patient identification, background description, account of system-based clinical details [p = .001] and notation of clinical details, code status, and goals [p < .002]. Interruptions decreased [p = .04] without any change in sign-out duration [p = .86]. The standard verbal template improved clinician satisfaction with sign-out, augmented the amount of information transferred and decreased interruptions without increasing the duration of sign-out.

Acute Decompensation in Pediatric Cardiac Patients: Outcomes After Rapid Response Events

Objective: We studied rapid response events after acute clinical instability outside ICU settings in pediatric cardiac patients. Our objective was to describe the characteristics and outcomes after rapid response events in this high-risk cohort and elucidate the cardiac conditions and risk factors associated with worse outcomes. Design: A retrospective single-center study was carried out over a 3-year period from July 2011 to June 2014. Setting: Referral high-volume pediatric cardiac center located within a tertiary academic pediatric hospital. Patients: All rapid response events that occurred during the study period were reviewed to identify rapid response events in cardiac patients. Interventions: None. Measurements and Main Results: We reviewed 1,906 rapid response events to identify 152 rapid response events that occurred in 127 pediatric cardiac patients. Congenital heart disease was the baseline diagnosis in 74% events (single ventricle, 28%; biventricle physiology, 46%). Seventy-four percent had a cardiac surgery before rapid response, 37% had ICU stay within previous 7 days, and acute kidney injury was noted in 41% post rapid response. Cardiac and/or pulmonary arrest occurred during rapid response in 8.5%. Overall, 81% were transferred to ICU, 22% had critical deterioration (ventilation or vasopressors within 12 hr of transfer), and 56% received such support and/or invasive procedures within 72 hours. Mortality within 30 days post event was 14%. Significant outcome associations included: single ventricle physiology—increased need for invasive procedures and mortality (adjusted odds ratio, 2.58; p = 0.02); multiple rapid response triggers—increased ICU transfer and interventions at 72 hours; critical deterioration—cardiopulmonary arrest and mortality; and acute kidney injury—cardiopulmonary arrest and need for hemodynamic support. Conclusions: Congenital heart disease, previous cardiac surgery, and recent discharge from ICU were common among pediatric cardiac rapid responses. Progression to cardiopulmonary arrest during rapid response, need for ICU care, kidney injury after rapid response, and mortality were high. Single ventricle physiology was independently associated with increased mortality.

142: OUTCOMES OF PEDIATRIC CARDIAC PATIENTS WITH ACUTE KIDNEY INJURY AT RAPID RESPONSE EVENTS

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) aVR, aVL, and aVF). We used the sum of the average QRS amplitudes for all the 6 limb leads as the overall QRS amplitude. V lead was not included because it is more sensitive to the posture of a patient. A linear regression between QRS amplitude and BNP level was calculated for each patient, and the percentage of patients with positive/negative correlation was reported. Results: The study consisted of 45 patients with more than 1 BNP lab test while admitted to the ICU from March 2013 to March 2015. Among the 45 patients, 51.1% (23/45) had a negative correlation between QRS amplitude and BNP level, while the other 48.9% (22/45) had a positive correlation. Conclusions: While the intrapatient changes of QRS amplitude alone cannot predict changes of BNP level, there may be other confounding variables such as body weight, treatment for establishing the relationship between serial QRS amplitudes and BNP levels. This will be the focus of a future study.

493: Etiology Is Crucial in Survival in Extra Corporeal Life Support in Cardiopulmonary Resuscitation

Introduction: ECPR has become more widely used in the resuscitation of pediatric cardiac arrest over the past two decades. Despite improving outcomes, controversy persists over the use of this therapy across all cardiac subgroups Methods: Retrospective chart review of all patients < 21 years who underwent ECPR at TCH from January 2005 to December 2012. The most recent Pediatric Overall Performance Score (POPC) was determined from the patients’ medical record. Results: During the study period, there were 103 deployments of Extra Corporeal Life Support (ECLS). Sixty-two deployments (60%) were for ECPR with twenty-seven patients (44%) surviving to discharge. Overall survival for patients with primary myocardial disease (myocarditis, cardiomyopathy or post-transplant) and congenital heart disease were similar (51% vs. 45%). There were no survivors in patients with restrictive cardiomyopathy, and only 14% of those with who required ECPR after transplant survived to discharge. Survival was higher for patients who were intubated (70%) at the time of arrest (p=0.001), whereas the presence of acute kidney injury at the time of the cardiac arrest (34%) was associated with higher mortality (p=0.06). A POPC < 2 (indicating good neurological performance) was present in 68% of survivors. Abnormal neuro-imaging prior to discharge was associated with poor neurological performance POPC > 2 (p=0.03). Conclusions: ECPR is associated with modest survival in children with heart disease, but this is in part associated with the underlying disease, as well as pre-existing comorbidities including the presence of acute kidney injury. This provides important data that can inform decision-making in this challenging patient group.

1361: Cultural Diversity in the Pediatric ICU

Introduction: America is culturally diverse, consisting of people with varied beliefs and values regarding death and dying. While clinicians strive for cultural sensitivity, the depth of this knowledge may be insufficient, particularly when providing palliative care. We report a case of end of life