Carl G.M. Weigle

Reduction of morbidity in interhospital transport by specialized pediatric staff

ObjectiveWe prospectively compared the occurrence of morbidity during high-risk interhospital transport in two types of transport systems: specialized tertiary center-based vs. nonspecialized, referring hospital-based. DesignConcurrent, prospective comparison of morbidity at two pediatric centers that use different types of transport team. SettingTwo tertiary care pediatric intensive care units (ICU). The specialized team consisted of a pediatric resident, pediatric intensive care nurse, and a pediatric respiratory therapist. Comparison was made with referring institution transports by nonspecialized personnel to a second center. The two centers were similar in size and patient mix, with referral areas of similar population and rural/urban ratio. PatientsOne hundred forty-one patients transported to two tertiary pediatric ICUs. InterventionsNone. Measurements and Main ResultsTwo types of events were assessed: vital signs and other observable clinical events were described as “physiologic deteriorations.” Events such as loss of intravenous access, endotracheal tube mishaps, and exhaustion of oxygen supply were described as “intensive care-related adverse events.” Pretransport severity of illness and therapy were described by Pediatric Risk of Mortality (PRIoM) and Iherapeutic Intervention Scoring System (TISS) scores. Only high-risk patients with PRISM scores of >10 were analyzed.Intensive care-related adverse events occurred in one (2%) of 49 transports by the specialized team and 18 (20%) of 92 transports by nonspecialized personnel. The difference is statistically significant (p < .05). Physiologic deterioration was similar in the two groups occurring in five (11%) of 47 specialized team transports and 11 (12%) of 92 transports by the nonspecialized team. ConclusionWe conclude that specialized pediatric teams can reduce transport morbidity. This is the first published study to compare two models of pediatric transport using identical definitions of severity and morbidity. (Crit Care Med 1994; 22:1186–1191)

Altered skin integrity in children admitted to a pediatric intensive care unit.

As part of a quality improvement study, the incidence and severity of altered skin integrity in a tertiary pediatric intensive care unit (PICU) were investigated in an attempt to identify contributing risk factors. Demographic, severity of illness, and practice variables were collected on 271 of 357 admissions during an 18-week period. Data were analyzed from the date of PICU admission until a change in skin integrity occurred or until PICU discharge. Altered skin integrity occurred in 26 percent of admissions; 7 percent of the cases had skin breakdown. By multivariate analysis, only the Pediatric Risk of Mortality Score and white race were associated with altered skin integrity.

Skin Breakdown in Children and High-Frequency Oscillatory Ventilation

OBJECTIVE To investigate the relationship of high-frequency oscillatory ventilation (HFOV) to skin breakdown on the scalp and ears in mechanically ventilated children. STUDY DESIGN Retrospective cohort study of 32 patients supported with HFOV paired with 32 patients supported with conventional mechanical ventilation (CV) in a pediatric intensive care unit (PICU). RESULTS By univariate analysis, more HFOV patients had skin breakdown than did the CV patients (53% vs 12.5%, p=.001); HFOV patients also had greater severity of illness (Pediatric Risk of Mortality scores), higher mortality, and longer durations of neuromuscular blockade, low systolic blood pressure, and time exposed to risk. Life table analysis demonstrated no difference in the rate of skin breakdown between HFOV and CV patients. Multifactorial analysis showed that only PICU time at risk was a risk factor for skin breakdown. CONCLUSIONS HFOV was not an independent risk factor for the development of skin breakdown. PICU time at risk was the sole risk factor for the development of skin breakdown in all mechanically ventilated patients in the PICU.

Use of active noise cancellation devices in caregivers in the intensive care unit.

Objective: Recent development of noise cancellation devices may offer relief from noise in the intensive care unit environment. This study was conducted to evaluate the effect of noise cancellation devices on subjective hearing assessment by caregivers in the intensive care units. Design: Randomized, double‐blind. Setting: Adult medical intensive care unit and pediatric intensive care unit of a teaching hospital. Subjects: Caregivers of patients, including nurses, parents, respiratory therapists, and nursing assistants from a medical intensive care unit and pediatric intensive care, were enrolled in the study. Intervention: Each participant was asked to wear the head‐phones, functional or nonfunctional noise cancellation devices, for a minimum of 30 mins. Measurements: Subjective ambient noise level was assessed on a 10‐point visual analog scale (VAS) before and during headphone use by each participant. Headphone comfort and the preference of the caregiver to wear the headphone were also evaluated on a 10‐point VAS. Simultaneously, objective measurement of noise was done with a sound level meter using the decibel‐A scale and at each of nine octave bands at each bedspace. Results: The functional headphones significantly reduced the subjective assessment of noise by 2 (out of 10) VAS points (p < 0.05) in environments of equal objective noise profiles, based on decibel‐A and octave band assessments. Conclusion: Noise cancellation devices improve subjective assessment of noise in caretakers. The benefit of these devices on hearing loss needs further evaluation in caregivers and critically ill patients.

The Internet, the electronic medical record, the pediatric intensive care unit, and everything.

This article details how computers have changed life for those of us in pediatric intensive care. A week of clinical activity is described, with a focus on the interactions with computer systems that have become an integral part of patient-care activities for many of us. It becomes clear that the boundaries between personal computers, hospital systems, and the Internet are often not sharply defined. Resources that are used every week may include those residing on a personal digital assistant, on the hospitals electronic medical record, or on a distant site on the World Wide Web. Key resources on the Internet (World Wide Web and e-mail) are identified. The technical underpinnings, particularly the network that provides the infrastructure for various resources, are described.

Treatment of an infant with tracheobronchomalacia at home with a lightweight, high-humidity, continuous positive airway pressure system

The conventional method of support for infants with severe tracheobronchomalacia (TBM) is continuous positive airway pressure (CPAP), generally delivered via tracheostomy tube by use of a ventilor or a continuous flow circuit with reservoir bag and water bath humidifier. These systems are difficult to use at home, and severely limit the locomotion of the developing infant. We report the use of two commercially available devices in a system that greatly increases infant mobility and provides better gas humidification than that provided by either of the more commonly used systems

Ambulatory Computerized Provider Order Entry (ACPOE or E-Prescribing)

Medical errors arise in part from variations in clinical care. Two broad sources of variations in care are: (a) the progressive complexity of health care (providers caring for more patients with multiple and/or chronic medical needs, less time in which to see them, fragmentation and lack of coordination of care) and (b) barriers (internal and external) that practitioners face in adhering to evidence-based treatment guidelines.1–3