Asya Agulnik

Validation of a Pediatric Early Warning Score in Hospitalized Pediatric Oncology and Hematopoietic Stem Cell Transplant Patients.

Objectives: To evaluate the correlation of a Pediatric Early Warning Score with unplanned transfer to the PICU in hospitalized oncology and hematopoietic stem cell transplant patients. Design: We performed a retrospective matched case–control study, comparing the highest documented Pediatric Early Warning Score within 24 hours prior to unplanned PICU transfers in hospitalized pediatric oncology and hematopoietic stem cell transplant patients between September 2011 and December 2013. Controls were patients who remained on the inpatient unit and were matched 2:1 using age, condition (oncology vs hematopoietic stem cell transplant), and length of hospital stay. Pediatric Early Warning Scores were documented by nursing staff at least every 4 hours as part of routine care. Need for transfer was determined by a PICU physician called to evaluate the patient. Setting: A large tertiary/quaternary free-standing academic children’s hospital. Patients: One hundred ten hospitalized pediatric oncology patients (42 oncology, 68 hematopoietic stem cell transplant) requiring unplanned PICU transfer and 220 matched controls. Interventions: None. Measurements and Main Results: Using the highest score in the 24 hours prior to transfer for cases and a matched time period for controls, the Pediatric Early Warning Score was highly correlated with the need for PICU transfer overall (area under the receiver operating characteristic = 0.96), and in the oncology and hematopoietic stem cell transplant groups individually (area under the receiver operating characteristic = 0.95 and 0.96, respectively). The difference in Pediatric Early Warning Score results between the cases and controls was noted as early as 24 hours prior to PICU admission. Seventeen patients died (15.4%). Patients with higher Pediatric Early Warning Scores prior to transfer had increased PICU mortality (p = 0.028) and length of stay (p = 0.004). Conclusions: We demonstrate that our institution’s Pediatric Early Warning Score is highly correlated with the need for unplanned PICU transfer in hospitalized oncology and hematopoietic stem cell transplant patients. Furthermore, we found an association between higher scores and PICU mortality. This is the first validation of a Pediatric Early Warning Score specific to the pediatric oncology and hematopoietic stem cell transplant populations, and supports the use of Pediatric Early Warning Scores as a method of early identification of clinical deterioration in this high-risk population.

Improved outcomes after successful implementation of a pediatric early warning system (PEWS) in a resource-limited pediatric oncology hospital.

Hospitalized pediatric oncology patients are at high risk of clinical decline and mortality, particularly in resource‐limited settings. Pediatric early warning systems (PEWS) aid in the early identification of clinical deterioration; however, there are limited data regarding their feasibility or impact in low‐resource settings. This study describes the successful implementation of PEWS at the Unidad Nacional de Oncología Pediátrica (UNOP), a pediatric oncology hospital in Guatemala, resulting in improved inpatient outcomes.

Validation of a pediatric early warning system for hospitalized pediatric oncology patients in a resource‐limited setting

Pediatric oncology patients are at high risk of clinical deterioration, particularly in hospitals with resource limitations. The performance of pediatric early warning systems (PEWS) to identify deterioration has not been assessed in these settings. This study evaluates the validity of PEWS to predict the need for unplanned transfer to the pediatric intensive care unit (PICU) among pediatric oncology patients in a resource‐limited hospital.

Pediatric Early Warning Systems aid in triage to intermediate versus intensive care for pediatric oncology patients in resource-limited hospitals

Pediatric oncology patients hospitalized in resource‐limited settings are at high risk for clinical deterioration resulting in mortality. Intermediate care units (IMCUs) provide a cost‐effective alternative to pediatric intensive care units (PICUs). Inappropriate IMCU triage, however, can lead to poor outcomes and suboptimal resource utilization. In this study, we sought to characterize patients with clinical deterioration requiring unplanned transfer to the IMCU in a resource‐limited pediatric oncology hospital. Patients requiring subsequent early PICU transfer had longer PICU length of stay. PEWS results prior to IMCU transfer were higher in patients requiring early PICU transfer, suggesting PEWS can aid in triage between IMCU and PICU care.

1296: IMPACT OF IMPLEMENTING A PEDIATRIC EARLY WARNING SYSTEM (PEWS) IN A PEDIATRIC ONCOLOGY HOSPITAL

Background: Hospitalized pediatric oncology and hematopoietic stem cell transplant (HSCT) patients have frequent clinical deterioration requiring transfer to the Pediatric Intensive Care Unit (PICU). Pediatric Early Warning Systems (PEWS) can aid early identification of clinical deterioration and improve outcomes in these patients. Objectives: Describe the impact of PEWS implementation in a dedicated pediatric hematology-oncology/HSCT hospital. Methods: A PEWS tool and escalation algorithm were implemented between August and October 2016 (Fig. 1). Implementation quality was evaluated by measuring errors in PEWS calculation, omissions, and algorithm activation. Frequency of emergency activations and method of unplanned PICU transfer were compared before and after PEWS implementation. Results: Random monitoring of PEWS scores demonstrated 12.7% calculation errors, 3.8% omissions, and 1.7% algorithm errors. Omissions and algorithm errors decreased over time following implementation (P < 0.0001 and P = 0.005, respectively). Frequency of Rapid Response Team (RRT) activations increased after PEWS implementation from 1.3 to 12.2/1,000-inpatient-days (P < 0.0001), without an increase in Code Blue activations (1.2 to 0.97/1,000-inpatient-days, P = 0.49, Fig. 2) and no change in frequency of unplanned PICU transfers (5.7/1,000-inpatient-days before and after PEWS implementation). Unplanned PICU transfers arriving via RRT increased from 11.5% to 60.5% of admissions (P < 0.0001, Fig. 3). Conclusions/Implications: PEWS can be successfully implemented in a pediatric hematology-oncology/HSCT hospital with improvement in accuracy over time. Implementation of PEWS resulted in increased use of the RRT system and more patients with clinical deterioration arriving to the PICU via an organized escalation pathway, representing standardization of care and improvement in the culture of safety in the hospital.

Combination Clearance Therapy and Barbiturate Coma for Severe Carbamazepine Overdose

This case report describes the successful treatment of a severe carbamazepine overdose using a combination of therapies and presents data suggesting mitochondrial dysfunction in carbamazepine intoxication. A 15-year-old female subject presented comatose, in respiratory failure and shock, after the intentional ingestion of ∼280 extended-release 200-mg carbamazepine tablets with a peak serum concentration of 138 µg/mL (583.74 µmol/L). The patient developed clinical seizures and an EEG pattern of stimulus-induced rhythmic, periodic, or ictal discharges, suggestive of significant cortical dysfunction. Due to the extremely high drug serum concentration and clinical instability, a combination of therapies was used, including lipid emulsion therapy, plasmapheresis, hemodialysis, continuous venovenous hemodiafiltration, and endoscopic intestinal decontamination. The patient’s elevated serum lactate level with a high mixed venous saturation suggested possible mitochondrial dysfunction, prompting treatment with barbiturate coma to reduce cerebral metabolic demand. The serum carbamazepine concentration declined steadily, with resolution of lactic acidosis, no long-term end-organ damage, and return to baseline neurologic function. The patient was eventually discharged in her usual state of health. In the laboratory, we demonstrated in vitro that the active metabolite of carbamazepine hyperpolarized the mitochondrial membrane potential, supporting the hypothesis that the drug caused mitochondrial dysfunction. We thus successfully treated a life-threatening carbamazepine overdose with a combination of modalities. Future studies are required to validate this aggressive approach. The occurrence of mitochondrial dysfunction must be confirmed in patients with carbamazepine toxicity and the need to treat it validated.

Successful Implementation of a Pediatric Early Warning Score in a Resource-Limited Pediatric Oncology Hospital in Guatemala

Abstract 25Background:Hospitalized pediatric oncology patients are at high risk for clinical decline and mortality, particularly in resource-limited settings. Pediatric Early Warning Scores (PEWS) are commonly used to aid with early identification of clinical deterioration; however, these scores have never been studied in oncology patients in low-resource settings. We describe the successful implementation of a modified PEWS at Unidad Nacional de Oncologia Pediatrica (UNOP), a national pediatric oncology hospital in Guatemala.Methods:The PEWS used at Boston Childrens Hospital (BCH) was modified through key informant meetings at UNOP, adjusting for practice variations between the two hospitals. After an initial pilot of the tool, the PEWS was implemented in all non-ICU inpatient areas at UNOP (60 beds with about 2,000 admissions/year). During implementation, systems were created to monitor errors in calculating PEWS, patient transfers to a higher level of care, and high PEWS scores for ongoing quality imp...