Amanda Levin

Evaluation of a Pediatric Early Warning Score Across Different Subspecialty Patients.

Objective: To evaluate the ability of a Pediatric Early Warning Score to predict deterioration in different subspecialty patient populations. Design: Single center, retrospective cohort study. Patients were classified into five groups: 1) cardiac; 2) hematology/oncology/bone marrow transplant; 3) surgical; 4) neurologic; and 5) general medical. The relationship between the Pediatric Early Warning Score and unplanned ICU transfer requiring initiation of specific ICU therapies (intubation, high-flow nasal cannula, noninvasive ventilation, inotropes, or aggressive fluid hydration within 12 hr of transfer) was evaluated. Setting: Tertiary care, free-standing, academic children’s hospital. Patients: All hospitalized acute care patients admitted over a 6-month time period (September 2012 to March 2013). Interventions: None. Measurements and Main Results: During the study time period, 33,800 patient-days and 136 deteriorations were evaluated. Area under the curve ranged from 0.88 (surgical) to 0.94 (cardiac). Sensitivities for a Pediatric Early Warning Score greater than or equal to 3 ranged from 75% (surgical) to 94% (cardiology) and number needed to evaluate to find one deterioration was 11.5 (neurologic) to 43 patients (surgical). Sensitivities for a Pediatric Early Warning Score greater than or equal to 4 ranged from 54% (general medical) to 79% (hematology/oncology/bone marrow transplant) and number needed to evaluate of 5.5 (neurologic) to 12 patients (general medical). Sensitivities for a Pediatric Early Warning Score of greater than or equal to 5 ranged from 25% (surgical) to 58% (hematology/oncology/bone marrow transplant) and number needed to evaluate of 3.5 (cardiac, hematology/oncology/bone marrow transplant, neurologic) to eight patients (surgical). Conclusions: An elevated Pediatric Early Warning Score is associated with ICU transfer and receipt of ICU-specific interventions in patients across different pediatric subspecialty patient populations.

Improving Pediatric Rapid Response Team Performance Through Crew Resource Management Training of Team Leaders

BACKGROUND Rapid response teams (RRTs) improve the detection of and response to deteriorating patients. Professional hierarchies and the multidisciplinary nature of RRTs hinder team performance. This study assessed whether an intervention involving crew resource management training of team leaders could improve team performance. METHODS In situ observations of RRT activations were performed pre- and post-training intervention. Team performance and dynamics were measured by observed adherence to an ideal task list and by the Team Emergency Assessment Measure tool, respectively. Multiple quartile (median) and logistic regression models were developed to evaluate change in performance scores or completion of specific tasks. RESULTS Team leader and team introductions (40% to 90%, P = .004; 7% to 45%, P = .03), floor team presentations in Situation Background Assessment Recommendation format (20% to 65%, P = .01), and confirmation of the plan (7% to 70%, P = .002) improved after training in patients transferred to the ICU (n = 35). The Team Emergency Assessment Measure metric was improved in all 4 categories: leadership (2.5 to 3.5, P < .001), teamwork (2.7 to 3.7, P < .001), task management (2.9 to 3.8, P < .001), and global scores (6.0 to 9.0, P < .001) for teams caring for patients who required transfer to the ICU. CONCLUSIONS Targeted crew resource management training of the team leader resulted in improved team performance and dynamics for patients requiring transfer to the ICU. The intervention demonstrated that training the team leader improved behavior in RRT members who were not trained.

Unscheduled Pediatric Intensive Care Unit Admissions in Patients With Cardiovascular Disease: Clinical Features and Outcomes.

Background: An unscheduled readmission to the intensive care unit (ICU) is associated with increased morbidity and mortality in children. There is a paucity of data examining the impact of unscheduled admissions on outcomes in children with specific disease processes such as cardiovascular disease. We investigated the impact of scheduled versus unscheduled ICU admission on clinical outcomes and differences in patient characteristics in children with cardiovascular disease. Methods: This was a retrospective analysis of contemporaneously collected clinical data using the Virtual PICU Systems database. All consecutive admissions at 102 participating pediatric ICUs in patients with cardiovascular disease were collected from October 2010 to September 2012. Results: There were 48,653 admissions included in the analysis (44% scheduled and 56% unscheduled). The median patient age was 31 months. Unscheduled admissions were associated with longer ICU length of stay and increased mortality (both P < .001). Adjusting for age, weight, and primary ICU admission diagnosis (cardiovascular vs noncardiovascular), patients with unscheduled admissions had an increased odds of mortality (odds ratio = 4.8, P < .001). Conclusions: Unscheduled ICU admissions were associated with worse clinical outcomes including increased mortality. Efforts targeted at reducing unscheduled admissions in at-risk patients are warranted.

1282: IMPROVING COMPLIANCE RATE FOR THROMBOPROPHYLAXIS IN CRITICALLY ILL ADULTS ADMITTED TO THE PICU

Learning Objectives: The American College of Chest Physicians (CHEST) has published guidelines for venous thromboembolism (VTE) prophylaxis in critically-ill adult patients. Patients of adult age are often admitted to the Pediatric Intensive Care Unit (PICU). We hypothesized that the VTE prophylaxis compliance rate in this population is low in our PICU. The aim of our quality improvement (QI) project was to increase the percentage of adult patients admitted to the PICU who receive adult VTE prophylaxis per the CHEST guidelines from 29% to 90% over 3 months. Methods: Our QI team collected baseline data of adherence to CHEST guidelines and performed a needs assessment of clinicians. A treatment algorithm that incorporated CHEST guidelines and our institutional needs was developed. This included delineation of inclusion and exclusion criteria for pharmacologic prophylaxis and suggested VTE prophylaxis agents (enoxaparin vs heparin vs sequential compression device). Our Plan-Do-Study-Act cycles included creation of the VTE prophylaxis algorithm, dissemination via a concise visual aid, and targeted education to critical care providers (RNs, trainees, APRNs, pharmacists, and attendings). The compliance rate for VTE prophylaxis was monitored monthly by chart review. Results: VTE prophylaxis compliance improved from 29% to 89% after3 months of improvement cycles. Barriers we encountered were lack of knowledge of adult guidelines, dissemination of information to a multi-disciplinary team, and hesitancy to implement new treatments in patients perceived to be high risk. Conclusions: We implemented a successful QI project to increase PICU providers’ adherence to the CHEST VTE prophylaxis guidelines in our growing population of adult patients in the PICU. Future efforts will focus on sustaining these results and addressing the VTE prophylaxis needs of adult-sized patients under the age of 18.