Kenneth P. Bandy

Continuous Quality Improvement: Reducing Unplanned Extubations in a Pediatric Intensive Care Unit

Objective. Unplanned extubation (UEX) is a potentially serious complication of mechanical ventilation. Limited information is available regarding factors that contribute to UEXs and subsequent reintubation of children. We monitored UEXs in our pediatric intensive care unit (PICU) for a 5-year period to assess the incidence and patient conditions associated with UEX and to evaluate whether targeted interventions were associated with a reduced rate of UEXs. Methods. Over a 5-year period, demographic and clinical information was collected prospectively on all patients who required an artificial airway while admitted to the PICU. Additional information was collected for patients who experienced an UEX. Educational sessions and care management protocols were developed, implemented, and modified according to issues identified via the monitoring program. Results. From a total of 2192 patients who required 13 630 airway days (AWD), 141 (6%) patients experienced 164 UEXs. The overall rate of UEX for the study period was 1.2 UEXs per 100 AWD, and this rate decreased from 1.5 in the first year to 0.8 in the last year. UEXs were more common in children who were younger than 5 years (1.6 vs 0.6 UEX per 100 AWD) compared with older children. The UEX children experienced significantly longer length of mechanical ventilation (6 vs 3 days) and longer length of PICU stay (8 vs 4 days) compared with non-UEX children. Forty-six percent of the UEXs occurred in patients who were weaning from mechanical ventilation, and 22% of those patients required reintubation. Conclusions. We conclude that UEX in pediatric patients is associated with longer length of mechanical ventilation and length of stay in the PICU. A continuous quality improvement monitoring and educational program that identified high-risk patients for UEX (younger patients) and patients who were at low risk for subsequent reintubation (weaning patients) contributed to a reduction of these potentially adverse events.

Clinical redesign using all patient refined diagnosis related groups.

Objective. Clinical redesign of processes in hospitals that care for children has been limited by a paucity of severity-adjusted indicators that are sensitive enough to identify areas of concern. This is especially true of hospitals that analyze pediatric patient care using standard Centers for Medicare and Medicaid Services (CMS) diagnosis-related groups (DRGs). The objectives of this study were to determine whether 1) utilization of all-patient refined (APR)-DRG severity-adjusted indicators (length of stay, cost per case, readmission rate) from the National Association of Childrens Hospitals and Related Institutions (NACHRI) database could identify areas for improvement at University of Michigan Mott Childrens Hospital (UMMCH) and 2) hospital staff could use the information to implement successful clinical redesign. Methods. The APR-DRG Classification System (version 20) was used with the NACHRI Case Mix Comparative Database by severity level comparison from 1999 to 2002. Indicators include average length of stay (ALOS), case mix index, cost per case, and readmission rate for low acuity asthma (APR-DRG 141.1). UMMCH cases of 141.1 (n = 511) were compared with NACHRI 141.1 (n = 64 312). Although not part of the standard report, mortality rates were calculated by NACHRI for UMMCH and an aggregate of NACHRI member childrens hospitals. Results. Data from 1999 revealed that in noncomplicated asthma cases (level 1 severity), the UMMCH ALOS versus NACHRI ALOS was slightly longer (UMMCH 2.16 days vs NACHRI 2.14 days), and the cost per case was higher (UMMCH

Compared effects of selected colloids on extravascular lung water in dogs after oleic acid-induced lung injury and severe hemorrhage

2824 vs NACHRI

Pandemic Influenza and Acute Care Centers: Taking Care of Sick Patients in a Nonhospital Setting

2738), whereas levels 2, 3, and 4 cases (moderate, major, and extreme severity) indicated the ALOS and cost per case were lower than the national aggregate. This showed that the APR-DRG system was sensitive enough to distinguish variances of care within a diagnosis according to severity level. After analysis of internal data and meeting with clinicians to review the indicators, 3 separate clinical processes were targeted: 1) correct documentation of comorbidities and complications, 2) standardized preprinted orders were created with the involvement of the pediatric pulmonologists, and 3) standardized automatic education for parents was started on the first day of admission. Yearly data were reviewed and appropriate adjustments made in the education of both residents and staff. In 2002, the UMMCH ALOS dropped to 1.75 ± .08 days from 2.16 ± .09. In 2002, the NACHRI ALOS was 2.00 days ± 0.01 versus the UMMCH ALOS of 1.75 days ± 0.0845, indicating that the UMMCH ALOS dropped significantly lower than the NACHRI aggregate database over the 3-year period. Cost per case of UMMCH compared with NACHRI after the 3 years indicated that UMMCH increased 12%, whereas the NACHRI aggregate increased 18%. These data show that length of stay and cost per case relative to the national database improved after clinical redesign. Improvements have been sustained throughout the 3-year period. Readmission rates ranged from 2.97% to 0.80% and were less than the national cohort by the third year. There were no mortalities in the UMMCH inpatient asthma program. This demonstrates that clinicians believed that the data from the APR-DRG acuity-adjusted system was useful and that they were then able to apply classical clinical redesign strategies to improve cost-effectiveness and quality that was sustained over 3 years. Conclusions. Severity-adjusted indicators were useful for identifying areas appropriate for clinical redesign and contributed to the improvement in cost-effective patient care without a detriment in quality indicators. This method of using a large comparative database, having measures of severity, and using internal analysis is generalizable for pediatric hospitals and can contribute to ongoing attempts to improve cost-effectiveness and quality in medical care.

Use of PEEP in acute respiratory distress syndrome in dogs.

While the hemodynamic effects of hydroxyethyl starch (HES) have been reported, the effect of this material upon extravascular lung water (EVLW) has not been investigated. Twenty mongrel dogs were subjected to both an oleic acid-induced lung injury and a 2-h period of hemorrhagic shock (MAP = 40 mm Hg). After reinfusion of shed blood, 5 dogs in each of 4 groups were given either 0.5 L of lactated Ringers solution or 0.5 L of 5% albumin, 6% dextran 75, or 6% HES. Lactated Ringers solution was then given in sufficient quantity to keep the wedge pressure (WP) at 12–15 mm Hg and Pao2, P(A-a)O2, cardiac index (CI) and oxygen delivery were determined. EVLW was measured by thermal-green dye double-indicator technique with an Edwards Lung Water Computer (American Edwards Laboratories, Santa Ana, CA). Mean baseline EVLW was 6.9 ± 0.3 ml/kg. Mean EVLW rose to 11.5 ± 1.9 ml/kg after oleic acid. One h after reinfusion, EVLW increased to 40.5 ± .4 ml/kg in the dogs given only lactated Ringers solution and to 39.5 ± 1.5 ml/kg in the dextran group. EVLW was 25.5 ± 3 ml/kg in the HES dogs, and 29.5 ± 2 ml/kg in the group given albumin. Differences between albumin and lactated Ringers solution and between the HES and lactated Ringers groups were significant (p < 0.02 and p < 0.05). Measurements of oxygen, ventilation, CI, and oxygen delivery were not significantly different between the albumin and HES subjects.

INHALED NITRIC OXIDE THERAPY IN NEONATES: EXPERIENCE WITH 70 PATIENTS AT ONE CENTER 1555

The ongoing spread of H5N1 avian influenza in Southeast Asia has raised concern about a worldwide influenza pandemic and has made clear the need to plan in advance for such an event. The federal government has stressed the importance of planning and, in particular, has asked hospitals and public health agencies to develop plans to care for patients outside of traditional healthcare settings. These alternative or acute care centers (ACCs) would be opened when hospitals, emergency departments (EDs), and clinics are overwhelmed by an influenza pandemic. The University of Michigan Hospital System (UMHS), a large tertiary care center in southeast Michigan, has been developing a model for offsite care of patients during an influenza pandemic. This article summarizes our planning efforts and the lessons learned from 2 functional exercises over the past 3 years.

DO PATIENT CHARACTERISTICS PREDICT RESPONSE TO INHALED NITRIC OXIDE FOR NEONATAL PERSISTENT PULMONARY HYPERTENSION? 1973

This study evaluates the effectiveness of combining mechanical ventilation and 5 cm H2O positive end-expiratory pressure (PEEP) at the onset of adult respiratory distress syndrome (ARDS) in dogs. Five cm H2O PEEP applied at the onset of ARDS in oleic acid injured dogs resulted in a decrease in cardiac output (CO). This decrease was accompanied by beneficial effects including a relatively stable Sao2 and Pao2. Control group dogs (receiving mechanical ventilation only) showed a less dramatic change in CO, but demonstrated a dramatic drop in saturation, compromising oxygen transport to the tissues. Thus, despite decrease in CO experienced by the PEEP group, oxygen extraction at the tissue level remained high.

1376 EARLY CLINICAL EXPERIENCE WITH PROXIMAL HIGH - FREQUENCY JET VENTILATION (HFJV) IN NEWBORNS

70 patients admitted to the University of Michigan Holden NICU from 21/1/93 through 11/15/96 received inhaled nitric oxide (NO) therapy. 62/70 patients were diagnosed with persistent pulmonary hypertension of the newborn (PPHN) as documented by echocardiogram and/or pre- and postductal PaO2 gradients. 8/70 patients were treated for persistent, intractable hypoxemia thought secondary to intrapulmonary shunt. A positive response was defined as an increase in postductal PaO2 to avoid ECMO. Permanent responders (28/70; 40%) were those who sustained a significant enough increase in postductal PaO2 to avoid ECMO. Transient responders (15/70; 21%) were those who had an initial positive response to inhaled NO, but could not sustain an adequate postductal PaO2, and required ECMO. Non-responders (27/70; 39%) were those who did not respond with an adequate increase in postductal PaO2 to an initial NO test of 40-80 ppm. Non-responders had a mean (+/- SD) baseline PaO2 of 45.6 (+/- 15.3) Torr. Mean baseline PaO2 in transient responders (38.6 +/- 14 Torr) was not significantly different from non-responders (P<0.2). Permanent responders had a significantly higher mean baseline PaO2 (62.6 +/- 25 Torr) over non-responders (P<0.005). Among the permanent responders, there were many more infants (10/28 responders vs. 3/27 non-responders) with radiographically diffuse underlying lung disease(RDS). Infants diagnosed with idiopathic PPHN were represented equally in all groups. Of 8 patients with congenital diaphragmatic hernia, 3 (37%) were responders, 1 (13%) was a transient responder and 4 (50%) were non-responders. There were an equal number of infants with underlying meconium aspiration syndrome and PPHN in both permanent responder and non-responder groups. All 8 infants without documented evidence of PPHN required ECMO. These limited data suggest there is a critical baseline level of oxygenation at or above which patients receiving NO may respond, and certain disease characteristics (e.g. PPHN with underlying diffuse disease) may be important in predicting NO response.

EFFECTS OF HIGH FREQUENCY JET VENTILATION ON PULMONARY AND HEMODYNAMIC PARAMETERS IN A RABBIT MODEL

DO PATIENT CHARACTERISTICS PREDICT RESPONSE TO INHALED NITRIC OXIDE FOR NEONATAL PERSISTENT PULMONARY HYPERTENSION? 1973

Feasibility of applying flow-synchronized ventilation to very low birthweight infants

Over a 10 month period 8 newborns (gestational ages 27-36 weeks, birthweights 770-3440 g and postnatal ages 2-16 d) were treated with HFJV for severe respiratory failure unresponsive to conventional mechanical ventilation (CMV). Diagnoses included tension pulmonary interstitial emphysema (PIE)-4, congenital diaphragmatic hernia (CDH)-2, and intractable pneumothoraees (PTX)-2.The Sechrist 990 High Frequency Jet Ventilator, a pulse-generated, solenoid-driven respirator was used. This device delivers a volume of gas at a controlled FiO2 and pressure to a jet located in the patient connector proximal to a standard single lumen endotracheal tube. The total volume of gas delivered to the lungs is comprised of the volume flowing through the jet and an additional volume entrained by the venturi effect. In most cases a Sechrist IV-100B was connected in tandem to provide low IMV CMV and improved humidifieation.Though only 2 of the 8 survived (one CDH, one PTX), all infants displayed marked short-term benefits from HFJV. Mean airway pressures could be lowered considerably without adverse effects on ventilation or oxygenation and with improvement in hemodynamic parameters. Radiographic improvement in PIE was noted in all 4 patients; elective paralysis could be discontinued in 7 of 8. None of the non-survivors displayed evidence of necrotizing tracheobronchitis.These preliminary results suggest short-term benefits of HFJV in severe respiratory failure. Further studies examining the use of HFJV earlier in the course of neonatal respiratory disease appear indicated.