Jason M. Kane

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

Objectives: To determine whether the implementation of a standardized handover protocol could reduce the number of errors occurring during patient transitions from the operating room to the intensive care unit. Design: Prospective, interventional study. Setting: Pediatric cardiac intensive care unit. Subjects: Seventy-nine patient handovers in patients transitioning from the operating room to the cardiac intensive care unit after congenital cardiac surgery. Interventions: A preintervention assessment of patient handovers was obtained by direct observation using a standardized checklist. A teamwork-driven handover process and protocol was developed using traditional and novel quality-improvement techniques. The postimplementation observational assessment of handovers was performed using the same preintervention assessment tool. Preintervention and postintervention data metrics were analyzed and compared. Measurements and Main Results: Forty-one and 38 observations were performed in the preintervention and postintervention periods, respectively. Protocol implementation improved key areas of the handover process. Technical errors per handover were reduced from 6.24 to 1.52 (p < .0001), and critical verbal handoff information omissions were reduced from 6.33 to 2.38 (p < .0001) per handover. There was no change in duration of either the verbal handoff briefing or the overall handover process. Caregivers noted improvement in teamwork and handoff content received after the intervention. Conclusions: A formal, structured handover process for pediatric patients transitioning to the intensive care unit after cardiac surgery can reduce medical errors that occur during the admission process and improve teamwork among caregivers.

Effects of pudendal nerve injury in the female rat

To test a neurogenic hypothesis for external urethral sphincter (EUS) dysfunction associated with urinary incontinence, the proximal pudendal nerve was crushed in anesthetized retired breeder female rats (n = 5) and compared with a sham lesion group (n = 4). Outcome measures included concentric needle electromyograms (EMGs) from the target EUS, voiding patterns during a 2‐hour dark period, and micturition data over a 24‐hour period. Fast Blue (FB) was introduced to the crush site at the time of injury and Diamidino Yellow (DY) to the EUS at the time the rats were killed (3 months post‐operative), when histological analysis of the nerve and urethra was also performed. EMG records indicated the EUS motor units undergo typical denervation changes followed by regeneration and recovery. Voiding patterns from the crush group show a significant increase of small urine marks in the front third of the cage. At 1–2 weeks post‐op, the frequency of voids was significantly increased in the crush group compared to pre‐op and late post‐op time periods. The mean volume voided in the light phase at the early post‐op time was significantly increased in the sham group. Light and electron microscopic patterns seen in nerve and muscle suggest the regenerating motor units maintain a structural integrity. Motoneurons in the lower lumbar cord were labeled with either DY (14.5 ± 6.8), FB (31.7 ± 23.7), or both (35.0 ± 17.5) tracers, indicating ∼54% of the crushed pudendal neurons regenerated to the EUS. In conclusion, several measures suggest this reversible crush lesion induces mild urinary incontinence. This animal model is promising for further development of hypotheses regarding neural injury, the pathogenesis of incontinence, and strategies aimed at prevention and treatment. Neurourol. Urodynam. 19:53–69, 2000.

Discordant identification of pediatric severe sepsis by research and clinical definitions in the SPROUT international point prevalence study

IntroductionConsensus criteria for pediatric severe sepsis have standardized enrollment for research studies. However, the extent to which critically ill children identified by consensus criteria reflect physician diagnosis of severe sepsis, which underlies external validity for pediatric sepsis research, is not known. We sought to determine the agreement between physician diagnosis and consensus criteria to identify pediatric patients with severe sepsis across a network of international pediatric intensive care units (PICUs).MethodsWe conducted a point prevalence study involving 128 PICUs in 26 countries across 6 continents. Over the course of 5 study days, 6925 PICU patients <18 years of age were screened, and 706 with severe sepsis defined either by physician diagnosis or on the basis of 2005 International Pediatric Sepsis Consensus Conference consensus criteria were enrolled. The primary endpoint was agreement of pediatric severe sepsis between physician diagnosis and consensus criteria as measured using Cohen’s κ. Secondary endpoints included characteristics and clinical outcomes for patients identified using physician diagnosis versus consensus criteria.ResultsOf the 706 patients, 301 (42.6 %) met both definitions. The inter-rater agreement (κ ± SE) between physician diagnosis and consensus criteria was 0.57 ± 0.02. Of the 438 patients with a physician’s diagnosis of severe sepsis, only 69 % (301 of 438) would have been eligible to participate in a clinical trial of pediatric severe sepsis that enrolled patients based on consensus criteria. Patients with physician-diagnosed severe sepsis who did not meet consensus criteria were younger and had lower severity of illness and lower PICU mortality than those meeting consensus criteria or both definitions. After controlling for age, severity of illness, number of comorbid conditions, and treatment in developed versus resource-limited regions, patients identified with severe sepsis by physician diagnosis alone or by consensus criteria alone did not have PICU mortality significantly different from that of patients identified by both physician diagnosis and consensus criteria.ConclusionsPhysician diagnosis of pediatric severe sepsis achieved only moderate agreement with consensus criteria, with physicians diagnosing severe sepsis more broadly. Consequently, the results of a research study based on consensus criteria may have limited generalizability to nearly one-third of PICU patients diagnosed with severe sepsis.

Lack of irrefutable validation does not negate clinical utility of near-infrared spectroscopy monitoring: Learning to trust new technology

Reliance on new monitoring device technology is based upon an understanding of how the device operates and its reliability in a specific clinical setting. The introduction of new monitoring devices will therefore elicit either distrust of the new technology and the data presented or adoption of new devices. The use of near-infrared spectroscopy (NIRS) technology to monitor vital organs in postoperative pediatric cardiac surgery patients has been extensively described yet controversy remains as to the use of this monitoring device. The following retrospective case series demonstrates how learning from trends in data elicited from 2-site NIRS monitoring provided important bedside insights. These insights led to changes in clinician behavior and reliance on NIRS monitoring for early recognition of clinically silent deteriorations. Disregard for the NIRS data may have led to a fatal outcome in an unstable patient who might have received more timely intervention if the NIRS data had been acknowledged earlier. This case series demonstrates that 2-site NIRS monitoring accurately reflects situations in which poor clinical outcomes may occur when declining trends in somatic tissue oxygen saturations are not corrected. Physician management of the postoperative pediatric cardiac surgery patient can change based upon the insights gained through the application of NIRS monitoring.

Impact of Patient Safety Mandates on Medical Education in the United States

Purpose: To determine the impact of the Institute of Medicine recommendations regarding patient safety on medical education resources in the United States. Methods: Medical textbooks representing major disciplines of medicine in the United States were surveyed for patient safety-related keywords, and content presented was quantified. Allopathic medical school curricula in the United States were reviewed for required or elective patient safety coursework using an on-line database, and specific curricula details were described. The Accreditation Council for Graduate Medical Education Residency Review Committee program requirements for accreditation were reviewed, and patient safety content was quantified. Results: Fifteen (54%) of the most recently published textbook editions reviewed contained patient safety information, and 11 of those (73%) specifically cited the Institute of Medicine report. Of the latest edition textbooks with safety keywords present, 67% dedicated entire chapters to patient safety or quality improvement. In 2007 and 2008, 10.4% of the 125 U.S. medical schools reported patient safety content in elective or required courses. All of the Accreditation Council for Graduate Medical Education Residency Review Committee program requirements contained patient safety content confined to systems-based practice and work-hour restrictions. Conclusions: Popular medical textbook content and core medical school and graduate medical education curricula do not adequately reflect the directive to increase patient safety education and reduce medical error.

Cervical abscess and mediastinal adenopathy: an unusual presentation of childhood histoplasmosis

Abstract. Histoplasmosis is the most common endemic respiratory mycosis in the United States. We report the clinical and imaging findings in a case of a child with the rare presentation of a neck abscess and mediastinal lymphadenopathy secondary to acute, non-disseminated histoplasmosis. Imaging findings often mimic other granulomatous infections such as tuberculosis or neoplastic processes such as lymphoma. Histoplasmosis should be considered in the differential diagnosis of a child who presents with enlarged mediastinal and cervical lymphadenopathy.

Maternal postpartum Group B Beta-hemolytic streptococcus ventriculoperitoneal shunt infection

Background.Women with cerebrospinal fluid shunts require special management during the course of pregnancy.Case report.We describe a case of delayed postpartum ventriculoperitoneal shunt infection by Group B streptococcus in a 19-year-old who presented complaining of headache and a fever. The CSF culture from the shunt tap and the distal shunt tip both grew Group B Beta-hemolytic streptococcus.Conclusion.Women who are colonized with Group B streptococcus and who have cerebrospinal fluid shunts should receive perinatal antibiotic prophylaxis, and may require more extended prophylactic antibiotics with cesarean section deliveries to prevent catheter tip colonization and subsequent shunt infection.

Case Volume and Outcomes of Congenital Diaphragmatic Hernia Surgery in Academic Medical Centers.

OBJECTIVE The outcome of patients with congenital diaphragmatic hernia (CDH) has not improved in the last decade and surgical repair remains the mainstay of treatment. The purpose of the present study was to assess whether a volume-outcome relationship exists in the U.S. academic medical centers performing surgical repair of neonatal CDH. STUDY DESIGN A retrospective cross-sectional analysis of discharge data for neonates undergoing CDH repair in academic medical center members of the University Health-System Consortium was employed. Unadjusted mortality was compared between lower and higher surgical volume centers. A binary logistic regression model was fit to test the relationship of surgical volume with mortality. RESULTS A total of 3,738 patients underwent surgical repair in 122 unique academic medical centers in the United States. The overall rate of survival was 75.2%. There was no difference in unadjusted mortality between lower and higher volume centers. After controlling for patient and hospital variables, there was no difference in the odds of mortality between lower and higher volume centers (odds ratio 1.03 [95% confidence interval, 0.86-1.23, p = 0.730]). CONCLUSIONS Neonates born with congenital diaphragmatic hernia can undergo surgical repair in the U.S. academic medical centers independent of center procedure volume and expect good surgical outcomes.

Association Between Postoperative Fever and Atelectasis in Pediatric Patients

Background: Postoperative fever is common after cardiac surgery. In the absence of documented infection, atelectasis is often suggested as a cause of postoperative fever. However, this link is not well supported by pathophysiologic mechanisms. The purpose of this study was to investigate whether an association exists between atelectasis and postoperative fever in pediatric patients undergoing cardiac surgery. Methods: A retrospective review was performed on consecutive pediatric patients who underwent cardiac surgery on cardiopulmonary bypass at a single cardiac surgery center from January 1, 2009, to December 31, 2009. Postoperative chest radiographs were evaluated and each lung was scored independently for atelectasis. Clinical parameters including the highest daily recorded temperature were noted and compared to atelectasis data. Results: A total of 203 patients were enrolled; 139 patients (68.5%) had fever at least once during the first 3 postoperative days. The incidence of atelectasis on each day was 41%, 57%, and 71%, respectively. There was no association between fever and atelectasis on any postoperative day (P = .21). Microbiological cultures were performed on 81 patients, and infection was found in 7 patients (3.5%). The frequency of either fever or atelectasis was similar between cyanotic and acyanotic patients. Conclusions: Postoperative fever and atelectasis are both common after pediatric cardiac surgery. In our study, there was no significant association between postoperative fever and atelectasis. In children undergoing cardiac surgery with cardiopulmonary bypass, fever in the postoperative period should not be attributed to atelectasis.

Nurses' perceptions of subspecialization in pediatric cardiac intensive care unit: quality and patient safety implications.

This study assessed the perceptions of nurses about the creation and staffing of a dedicated cardiac intensive care unit. Nurses perceived a clinical benefit to cohorting cardiac surgery patients; however, they reported more knowledge deficits in cardiac patient care than other intensive care unit disease categories. More than 25% of nurses reported a patient assignment in which they identified suboptimal skills to provide safe patient care. Years of clinical experience did not reduce concerns for quality of care or safe practice.