Binita Patel

Implementation of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency Department

BACKGROUND: Suboptimal care for children with septic shock includes delayed recognition and inadequate fluid resuscitation. OBJECTIVE: To describe the implementation of an emergency department (ED) protocol for the recognition of septic shock and facilitate adherence to national treatment guidelines. PATIENTS AND METHODS: Root-cause analyses and morbidity and mortality conferences identified system problems with sepsis recognition and management. A group of ED and critical care physicians met to identify barriers and create solutions. RESULTS: To facilitate sepsis recognition, a computerized triage system alarmed on abnormal vital signs, and then toxic-appearing children or children at high risk for invasive infection were placed in a resuscitation room. To facilitate timely delivery of interventions, additional nursing, respiratory therapy, and pharmacy personnel were recruited. Fluids were administered via syringe delivery; standardized laboratory studies and antibiotics were ordered and prioritized. Frequent vital-sign measurements and interventions were documented on a graphical flow sheet to facilitate interpretation of physiologic response to therapy. After protocol initiation, there were 191 encounters in 167 patients with suspected sepsis. When compared with children seen before the protocol, time from triage to first bolus decreased from a median of 56 to 22 minutes (P < .001) and triage to first antibiotics decreased from a median of 130 to 38 minutes (P < .001). CONCLUSIONS: The protocol resulted in earlier recognition of suspected sepsis and substantial reductions in both time to receipt of time-sensitive interventions and a decrement in treatment variation.

Outside the Box and Into Thick Air: Implementation of an Exterior Mobile Pediatric Emergency Response Team for North American H1N1 (Swine) Influenza Virus in Houston, Texas

Study objective We describe the implementation of a mobile pediatric emergency response team for mildly ill children with influenza-like illnesses during the H1N1 swine influenza outbreak. Methods This was a descriptive quality improvement study conducted in the Texas Childrens Hospital (Houston, TX) pediatric emergency department (ED), covered, open-air parking lot from May 1, 2009, to May 7, 2009. Children aged 18 years or younger were screened for viral respiratory symptoms and sent to designated areas of the ED according to level of acuity, possibility of influenza-like illness, and the anticipated need for laboratory evaluation. Results The mobile pediatric emergency response team experienced 18% of the total ED volume, or a median of 48 patients daily, peaking at 83 patients treated on May 3, 2009. Although few children had positive rapid influenza assay results and the morbidity of disease in the community appeared to be minimal for the majority of children, anxiety about pandemic influenza drove a large number of ED visits, necessitating an increase in surge capacity. Surge capacity was augmented both through utilization of existing institutional resources and by creating a novel area in which to treat patients with potential airborne pathogens. Infection control procedures and patient safety were also maximized through patient cohorting and adaptation of social distancing measures to the ED setting. Conclusion The mobile pediatric emergency response team and screening and triage algorithms were able to safely and effectively identify a group of low-acuity patients who could be rapidly evaluated and discharged, alleviating ED volume and potentially preventing transmission of H1N1 influenza.

Implementation of an In Situ Qualitative Debriefing Tool for Resuscitations

AIM Multiple guidelines recommend debriefing of resuscitations to improve clinical performance. We implemented a novel standardized debriefing program using a Debriefing In Situ Conversation after Emergent Resuscitation Now (DISCERN) tool. METHODS Following the development of the evidence-based DISCERN tool, we conducted an observational study of all resuscitations (intubation, CPR, and/or defibrillation) at a pediatric emergency department (ED) over one year. Resuscitation interventions, patient survival, and physician team leader characteristics were analyzed as predictors for debriefing. Each debriefings participants, time duration, and content were recorded. Thematic content of debriefings was categorized by framework approach into Team Emergency Assessment Measure (TEAM) elements. RESULTS There were 241 resuscitations and 63 (26%) debriefings. A higher proportion of debriefings occurred after CPR (p<0.001) or ED death (p<0.001). Debriefing participants always included an attending and nurse; the median number of staff roles present was six. Median intervals (from resuscitation end to start of debriefing) & debriefing durations were 33 (IQR 15, 67) and 10 min (IQR 5, 12), respectively. Common TEAM themes included co-operation/coordination (30%), communication (22%), and situational awareness (15%). Stated reasons for not debriefing included: unnecessary (78%), time constraints (19%), or other reasons (3%). CONCLUSIONS Debriefings with the DISCERN tool usually involved higher acuity resuscitations, involved most of the indicated personnel, and lasted less than 10 min. Future studies are needed to evaluate the tool for adaptation to other settings and potential impacts on education, quality improvement programming, and staff emotional well-being.

Test characteristics of an automated age- and temperature-adjusted tachycardia alert in pediatric septic shock.

Objectives This study aimed to create and analyze the performance of an automated triage tool alerting triage nursing staff and physicians to an abnormal heart rate consistent with septic shock in a pediatric emergency department. Methods A computerized best-practice alert (BPA) triage system corrected heart rate for temperature (5 beats per minute for each 1°F above 100°F or 9.6–10 beats per minute for each 1°C > 36°C) and alarmed on tachycardia. If patients appeared ill and/or had medical comorbidities predisposing them to sepsis, a “shock protocol” was activated. Sensitivity was calculated for patients clinically diagnosed with shock during the study period. Results During the study period (February to August 2010), the BPA was triggered in 4552 (11.5%) of 39,697 visits. Mean age was 5.4 years (range, 18 days to 18 years); 53% were female. The tool was 81% sensitive in identifying the 210 patients with shock. Missed patients were more likely to be previously healthy (odds ratio, 2.7; 95% confidence interval, 1.2–6.2), younger (5.7 vs 8.7 years, P = 0.004), and less likely to have a malignancy (odds ratio, 0.38; 95% confidence interval, 0.2–0.8). The tool was 89% specific; positive and negative predictive values were 4% and 99.9%, respectively. Conclusions The BPA-automated sensitive triage tool, based solely on initial temperature and heart rate, led to the identification of most children with septic shock, even before clinical acumen and laboratory values were incorporated into the diagnostic algorithm.

Resuscitation Bundle in Pediatric Shock Decreases Acute Kidney Injury and Improves Outcomes

OBJECTIVE To investigate the impact of an early emergency department (ED) protocol-driven resuscitation (septic shock protocol [SSP]) on the incidence of acute kidney injury (AKI). STUDY DESIGN This was a retrospective pediatric cohort with clinical sepsis admitted to the pediatric intensive care unit (PICU) from the ED before (2009, PRE) and after (2010, POST) implementation of the SSP. AKI was defined by pRIFLE (pediatric version of the Risk of renal dysfunction; Injury to kidney; Failure of kidney function; Loss of kidney function, End-stage renal disease creatinine criteria). RESULTS A total of 202 patients (PRE, n = 98; POST, n = 104) were included (53% male, mean age 7.7 ± 5.6 years, mean Pediatric Logistic Organ Dysfunction [PELOD] 8.9 ± 12.7, mean Pediatric Risk of Mortality score 5.3 ± 13.9). There were no differences in demographics or illness severity between the PRE and POST groups. POST was associated with decreased AKI (54% vs 29%, P < .001), renal-replacement therapy (4 vs 0, P = .04), PICU, and hospital lengths of stay (LOS) (1.9 ± 2.3 vs 4.5 ± 7.6, P < .01; 6.3 ± 5.1 vs 15.3 ± 16.9, P < .001, respectively), and mortality (10% vs 3%, P = .037). The SSP was independently associated with decreased AKI when we controlled for age, sex, and PELOD (OR 0.27, CI 0.13-0.56). In multivariate analyses, the SSP was independently associated with shorter PICU and hospital LOS when we controlled for AKI and PELOD (P = .02, P < .001, respectively). CONCLUSION A protocol-driven implementation of a resuscitation bundle in the pediatric ED decreased AKI and need for renal-replacement therapy, as well as PICU and hospital LOS and mortality.

A novel briefing checklist at shift handoff in an emergency department improves situational awareness and safety event identification

Objectives Emergency department (ED) shift handoffs are sources of potential medical error, delays in care, and medicolegal liabilities. Few handoff studies exist in the ED literature. We aimed to describe the implementation of a standardized checklist for improving situational awareness during physician handoffs in a pediatric ED. Methods This is a descriptive observational study in a large academic pediatric ED. Checklists were evaluated for rates of use, completion, and identification of potential safety events. We defined a complete checklist as 80% or more of items checked.   A user perception survey was used. After 1 year, all checklist users (residents, fellows, faculty, and charge nurses with ED experience before and after checklist implementation) were anonymously surveyed to assess the checklist’s usability, perceived contributions to Institute of Medicine quality domains, and situational awareness. The electronically administered survey used Likert frequency scales. Results Of 732 handoffs, 98% used the checklist, and 89% were complete. A mean of 1.7 potential safety events were identified per handoff. The most frequent potential safety events were identification of intensive care unit–level patients in the ED (48%), equipment problems (46%), staffing issues (21%), and intensive care unit–level patients in transport (16%). Eighty-one subjects (88%) responded to the survey. The users agreed that the checklist promoted better communication, safety, efficiency, effective care, and situational awareness. Conclusions The Physician Active Shift Signout in the Emergency Department briefing checklist was used often and at a high completion rate, frequently identifying potential safety events. The users found that it improved the quality of care and team communication. Future studies on outcomes and processes are needed.

Etiologies of septic shock in a pediatric emergency department population.

Knowledge of pediatric sepsis etiologies is needed to optimize empiric therapy. A retrospective cross-sectional review of 428 children with clinically diagnosed sepsis found that 13% had lobar pneumonia, 12% bacteremia and 10% viral infections. No etiologies were found in 76%. Empiric antibiotic coverage of vancomycin/piperacillin-tazobactam/gentamicin for immunocompromised children and vancomycin/nafcillin/cefotaxime for previously healthy children would have covered all bacteremic children.

Effect of a triage team on length of stay in a pediatric emergency department.

Objective: This study aimed to determine the impact of a triage team on patient length of stay (LOS) overall and by patient acuity in a pediatric emergency department (ED). Methods: We conducted a cluster randomized controlled trial in which existing ED staffing was reallocated to include a triage team. The study was conducted in an urban childrens ED Monday through Friday, from 6:00 p.m. to 2:00 a.m., for 4 weeks in February 2008. Twenty study periods were randomized according to the absence or presence of a triage team (physician, nurse, and nurse assistant) that initiated evaluations of nonurgent and urgent patients. We compared patient LOS between study periods with and without triage teams, using generalized estimating equations to allow for the clustering of effects by day. Results: Of the 1726 patients, 843 were seen during nontriage team times and 883 during triage team times. Overall, there was a 21-minute decrease in LOS during triage team times compared with nontriage team times, but this was not statistically significant. Stratifying by patient acuity level, LOS was significantly decreased during triage team times for nonurgent (25 minutes, P = 0.001) and urgent patients (50 minutes, P = 0.047) but prolonged for emergent patients (79 minutes, P = 0.019) and unchanged for critically ill patients. Conclusions: Overall, although we did not find a statistically significant decrease in the LOS with the use of a dedicated triage team, we did find statistically significant decreases in the stratified analysis for urgent, nonurgent patient, and discharged patients. An important reason statistical significance may not have been reached in this study may have been our hospitals current staffing model, and therefore, the use of a triage team as additional staffing versus reallocation of existing staffing may depend on an institutions current level of staffing and its ability to meet patient demand.

Time-driven activity-based costing to identify opportunities for cost reduction in pediatric appendectomy

PURPOSE As reimbursement programs shift to value-based payment models emphasizing quality and efficient healthcare delivery, there exists a need to better understand process management to unearth true costs of patient care. We sought to identify cost-reduction opportunities in simple appendicitis management by applying a time-driven activity-based costing (TDABC) methodology to this high-volume surgical condition. METHODS Process maps were created using medical record time stamps. Labor capacity cost rates were calculated using national median physician salaries, weighted nurse-patient ratios, and hospital cost data. Consumable costs for supplies, pharmacy, laboratory, and food were derived from the hospital general ledger. RESULTS Time-driven activity-based costing resulted in precise per-minute calculation of personnel costs. Highest costs were in the operating room (

Time-driven activity-based costing: A dynamic value assessment model in pediatric appendicitis☆

747.07), hospital floor (