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Dive into the research topics where Matthew R. Mittiga is active.

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Featured researches published by Matthew R. Mittiga.


Annals of Emergency Medicine | 2012

Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review

Benjamin T. Kerrey; Andrea S. Rinderknecht; Gary L. Geis; Lise E. Nigrovic; Matthew R. Mittiga

STUDY OBJECTIVE Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED). METHODS We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success. RESULTS We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined. CONCLUSION Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.


Annals of Emergency Medicine | 2013

The Spectrum and Frequency of Critical Procedures Performed in a Pediatric Emergency Department: Implications of a Provider-Level View

Matthew R. Mittiga; Gary L. Geis; Benjamin T. Kerrey; Andrea S. Rinderknecht

STUDY OBJECTIVE We seek to provide current, comprehensive, and physician-level data for critical procedures performed in a high-volume pediatric emergency department (ED). METHODS We conducted a retrospective study of all critical procedures performed in the ED of a tertiary care pediatric institution. Data were collected from written records of resuscitative care provided. The primary outcome measure was the cumulative frequency of each critical procedure during 12 consecutive months. Additional outcome measures included the number of critical procedures performed by pediatric emergency medicine faculty and fellows and a description of the other physician types performing each procedure. RESULTS Two hundred sixty-one critical procedures were performed during 194 patient resuscitations, which represented 0.22% of all ED patient evaluations. Sixty-one percent of pediatric emergency medicine faculty did not perform a single critical procedure. Orotracheal intubation occurred 147 times and represented 56% of all critical procedures, yet 63% of pediatric emergency medicine faculty did not perform a single successful orotracheal intubation. Pediatric emergency medicine fellows performed a median of 3 critical procedures. CONCLUSION Critical procedures were rarely performed in a large, academic pediatric ED. Pediatric emergency medicine faculty are at significant risk for skill deterioration, and pediatric emergency medicine fellows are unlikely to achieve competence in the performance of critical procedures if clinical exposure is the sole basis for the attainment and maintenance of skill.


Pediatric Emergency Care | 2008

Atlantoaxial rotary subluxation after minor trauma.

Brad Sobolewski; Matthew R. Mittiga; Jennifer L. Reed

We present a case of atlantoaxial rotary subluxation after a minor injury managed by manual reduction under sedation. Atlantoaxial rotary subluxation should be considered in a child with inability or unwillingness to turn their head when history and physical examination do not suggest torticollis of benign etiology. In our discussion, we review etiology, diagnosis, as well as pre- and in-hospital management.


BMJ Quality & Safety | 2015

Reducing the incidence of oxyhaemoglobin desaturation during rapid sequence intubation in a paediatric emergency department

Benjamin T. Kerrey; Matthew R. Mittiga; Andrea S. Rinderknecht; Kartik Varadarajan; Jenna Dyas; Gary L. Geis; Joseph W. Luria; Mary Frey; Tamara Jablonski; Srikant B. Iyer

Objectives Rapid sequence intubation (RSI) is the standard for definitive airway management in emergency medicine. In a video-based study of RSI in a paediatric emergency department (ED), we reported a high degree of process variation and frequent adverse effects, including oxyhaemoglobin desaturation (SpO2<90%). This report describes a multidisciplinary initiative to improve the performance and safety of RSI in a paediatric ED. Methods We conducted a local improvement initiative in a high-volume academic paediatric ED. We simultaneously tested: (1) an RSI checklist, (2) a pilot/copilot model for checklist execution, (3) the use of a video laryngoscope and (4) the restriction of laryngoscopy to specific providers. Data were collected primarily by video review during the testing period and the historical period (2009–2010, baseline). We generated statistical process control charts (G-charts) to measure change in the performance of six key processes, attempt failure and the occurrence of oxyhaemoglobin desaturation during RSI. We iteratively revised the four interventions through multiple plan-do-study-act cycles within the Model for Improvement. Results There were 75 cases of RSI during the testing period (July 2012–September 2013). Special cause variation occurred on the G-charts for three of six key processes, attempt failure and desaturation, indicating significant improvement. The frequency of desaturation was 50% lower in the testing period than the historical (16% vs 33%). When all six key processes were performed, only 6% of patients experienced desaturation. Conclusions Following the simultaneous introduction of four interventions in a paediatric ED, RSI was performed more reliably, successfully and safely.


Academic Emergency Medicine | 2017

Studying the Safety and Performance of Rapid Sequence Intubation: Data Collection Method Matters

Andrea S. Rinderknecht; Jenna Dyas; Benjamin T. Kerrey; Gary L. Geis; Mona H Ho; Matthew R. Mittiga

OBJECTIVE We sought to describe and compare chart and video review as data collection sources for the study of emergency department (ED) rapid sequence intubation (RSI). METHODS This retrospective cohort study compares the availability and content of key RSI outcome and process data from two sources: chart and video data from 12 months of pediatric ED RSI. Key outcomes included adverse effects (oxyhemoglobin desaturation, physiologic changes, inadequate paralysis, vomiting), process components (number of laryngoscopy attempts, end-tidal CO2 detection), and timing data (duration of preoxygenation and laryngoscopy attempts). RESULTS We reviewed 566 documents from 114 cases with video data. Video review detected higher rates of adverse effects (67%) than did chart review (46%, p < 0.0001), identifying almost twice the rate of desaturation noted in the chart (34% vs. 18%, p = 0.0002). The performance and timing of key RSI processes were significantly more reliably available via video review (timing and duration of preoxygenation, as well as timing, duration, and number of laryngoscopy attempts, all p < 0.05). Video review identified 221 laryngoscopy attempts, whereas chart review only identified 187. CONCLUSIONS When compared with video review for retrospective study of RSI in a pediatric ED, chart review significantly underestimated adverse effects, inconsistently contained data on important RSI process elements, rarely provided time data, and often conflicted with observations made on video review. Interpretation of and design of future studies of RSI should take into consideration the quality of the data source.


Pediatric Emergency Care | 2017

Toxicological Emergencies in the Resuscitation Area of a Pediatric Emergency Department: A 12-Month Review.

Gillian A. Beauchamp; Benjamin T. Kerrey; Matthew R. Mittiga; Andrea S. Rinderknecht; Shan Yin

Objective Few studies of children with toxicological emergencies describe those undergoing acute resuscitation, and most describe exposures to single agents. We describe a 12-month sample of patients evaluated in the resuscitation area of a pediatric emergency department (ED) for a toxicological emergency. Methods We conducted a retrospective chart review of patients in a high-volume, academic pediatric ED. We identified patients evaluated in the ED resuscitation area for toxicological exposure and conducted structured chart reviews to collect relevant data. For all variables of interest, we calculated standard descriptive statistics. Results Of 2999 patients evaluated in the resuscitation area through 12 months (March 2009 to April 2010), we identified 80 (2.7%) whose primary ED diagnosis was toxicological. The mean age was 11.4 years. Eighty-six percent of patients were triaged to the resuscitation area for significantly altered mental status. The most frequent single exposures were ethanol (25%), clonidine (10%), and acetaminophen (5%). At least 1 laboratory test was performed for almost all patients (97%). Interventions performed in the resuscitation area included intravenous access placement (97%), activated charcoal (20%), naloxone (19%), and endotracheal intubation (12%). Eighty-two percent of patients were admitted to the hospital; 37% to the intensive care unit. No patients studied in this sample died and most received only supportive care. Conclusions In a high-volume pediatric ED, toxicological emergencies requiring acute resuscitation were rare. Ethanol and clonidine were the most frequent single exposures. Most patients received diagnostic testing and were admitted. Further studies are needed to describe regional differences in pediatric toxicological emergencies.


Annals of Emergency Medicine | 2017

Is Tachycardia at Discharge From the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study

Paria Majd Wilson; Todd A. Florin; Guixia Huang; Matthew Fenchel; Matthew R. Mittiga

Study objective: We evaluate the association between discharge tachycardia and (1) emergency department (ED) and urgent care revisit and (2) receipt of clinically important intervention at the revisit. Methods: The study included a nonconcurrent cohort of children aged 0 to younger than 19 years, discharged from 2 pediatric EDs and 4 pediatric urgent care centers in 2013. The primary exposure was discharge tachycardia (last recorded pulse rate ≥99th percentile for age). The main outcome was ED or urgent care revisit within 72 hours of discharge. Additional outcomes included interventions received and disposition at the revisit, prevalence of discharge tachycardia at the index visit, and associations of pain, fever, and medications with discharge tachycardia. Multivariable logistic regression determined relative risk ratios for revisit and receipt of clinically important intervention at the revisit. Results: Of eligible visits, 126,774 were included, of which 10,470 patients (8.3%) had discharge tachycardia. Discharge tachycardia was associated with an increased risk of revisit (adjusted RR 1.3; 95% confidence interval 1.2 to 1.5), increased risk of tachycardia at the revisit (relative risk 3.1; 95% confidence interval 2.6 to 3.7), and of the receipt of certain clinically important interventions (supplemental oxygen, respiratory medications and admission, antibiotics and admission, and peripheral intravenous line placement and admission). However, there was no increased risk for the composite outcome of receipt of any clinically important intervention or admission on revisit. Conclusion: Discharge tachycardia is associated with an increased risk of revisit. It is likely that tachycardia at discharge is not a critical factor associated with impending physiologic deterioration.


Annals of Emergency Medicine | 2017

High Risk, Low Frequency: Optimizing Performance of Emergency Intubation for Children

Benjamin T. Kerrey; Andrea S. Rinderknecht; Matthew R. Mittiga

Emergency intubation is a high-risk, low-frequency procedure for pediatric patients. Providers must perform emergency intubation for children competently and safely, yet exposure is rare for individual providers. The infrequency of exposure creates substantial challenges for trainees and established providers, limiting opportunities to achieve and maintain competency, to develop a confident and comprehensive approach, and, for patients, to minimize the risk of adverse events. Efficient placement of an endotracheal tube during the initial laryngoscopy attempt is a standard measure of procedural success. Compared with adults, for whom published rates of first-attempt success range from 75% to 83%, emergency intubation for children is generally less successful, with rates ranging from 33% to 83% in the emergency department and ICU and from 66% to 79% in the out-of-hospital setting. Adverse events are also more common in children, with oxyhemoglobin desaturation reported in 33% to 47% compared with 0.5% to 26% of adults. With efficient and safe intubation elusive for pediatric patients in a low-exposure environment, how do individuals performing this procedure respond?


Pediatric Emergency Care | 2016

Essentials of Pediatric Emergency Medicine Fellowship: Part 1: An Overview.

Pavan Zaveri; Deborah C. Hsu; Matthew R. Mittiga; Margaret Wolff; Stacy Reynolds; In Kim; Coburn H. Allen; Constance McAneney; Maybelle Kou

This article is the first in a 7-part series (Table 1) that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated on program completion. This overview article provides a framework for the series.


Pediatric Emergency Care | 2016

A Survey Assessment of Perceived Importance and Methods of Maintenance of Critical Procedural Skills in Pediatric Emergency Medicine.

Matthew R. Mittiga; Michael FitzGerald; Benjamin T. Kerrey

Supplemental digital content is available in the text. Objective The aim of this study was to delineate pediatric emergency medicine provider opinions regarding the importance of, and to ascertain existing processes by which practitioners maintain, the following critical procedural skills: oral endotracheal intubation, intraosseous line placement, pharmacologic and electrical cardioversion, tube thoracostomy, and defibrillation. Methods A customized survey was administered to all members of the Listserv for the American Academy of Pediatrics Section on Emergency Medicine. Perceived importance of maintaining critical pediatric procedural skills was measured using a 5-point Likert-type scale. Secondary outcomes included presence and type of mandatory training, availability of on-site backup, and perceived barriers to maintenance of skills. Results Two hundred sixty-two members (25%) responded representing 106 different institutions, 70% of freestanding children’s hospitals that received graduate medical education payments in 2014, and 68% of pediatric emergency medicine fellowship programs. More than 90% of respondents felt it was either very or extremely important to maintain competency for 5 of the 6 critical procedures, but no more than 49% of respondents felt that clinical care alone provided opportunity to maintain skills. The proportion of respondents indicating no mandatory training for each critical procedural skill was as follows: oral endotracheal intubation (23%), intraosseous line placement (30%), pharmacologic cardioversion (32%), electrical cardioversion (32%), tube thoracostomy (40%), and defibrillation (32%). Conclusions Critical procedural skills are perceived by emergency providers who care for children as extremely important to maintain. Direct care of pediatric patients likely does not provide sufficient opportunity to maintain these skills. There are widespread deficiencies relating to mandatory maintenance of critical procedural skill training.

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Benjamin T. Kerrey

Cincinnati Children's Hospital Medical Center

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Andrea S. Rinderknecht

Cincinnati Children's Hospital Medical Center

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Gary L. Geis

Cincinnati Children's Hospital Medical Center

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Javier A. Gonzalez del Rey

Cincinnati Children's Hospital Medical Center

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Jenna Dyas

Cincinnati Children's Hospital Medical Center

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Mary Frey

Cincinnati Children's Hospital Medical Center

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Srikant B. Iyer

Cincinnati Children's Hospital Medical Center

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Brad Sobolewski

Cincinnati Children's Hospital Medical Center

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Constance McAneney

Cincinnati Children's Hospital Medical Center

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Joseph W. Luria

Cincinnati Children's Hospital Medical Center

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