Sandeep Gangadharan

Differences in the Quality of Pediatric Resuscitative Care Across a Spectrum of Emergency Departments

Importance The quality of pediatric resuscitative care delivered across the spectrum of emergency departments (EDs) in the United States is poorly described. In a recent study, more than 4000 EDs completed the Pediatric Readiness Survey (PRS); however, the correlation of PRS scores with the quality of simulated or real patient care has not been described. Objective To measure and compare the quality of resuscitative care delivered to simulated pediatric patients across a spectrum of EDs and to examine the correlation of PRS scores with quality measures. Design, Setting, and Participants This prospective multicenter cohort study evaluated 58 interprofessional teams in their native pediatric or general ED resuscitation bays caring for a series of 3 simulated critically ill patients (sepsis, seizure, and cardiac arrest). Main Outcomes and Measures A composite quality score (CQS) was measured as the sum of 4 domains: (1) adherence to sepsis guidelines, (2) adherence to cardiac arrest guidelines, (3) performance on seizure resuscitation, and (4) teamwork. Pediatric Readiness Survey scores and health care professional demographics were collected as independent data. Correlations were explored between CQS and individual domain scores with PRS. Results Overall, 58 teams from 30 hospitals participated (8 pediatric EDs [PEDs], 22 general EDs [GEDs]). The mean CQS was 71 (95% CI, 68-75); PEDs had a higher mean CQS (82; 95% CI, 79-85) vs GEDs (66; 95% CI, 63-69) and outperformed GEDs in all domains. However, when using generalized estimating equations to estimate CQS controlling for clustering of the data, PED status did not explain a higher CQS (β = 4.28; 95% CI, -4.58 to 13.13) while the log of pediatric patient volume did explain a higher CQS (β = 9.57; 95% CI, 2.64-16.49). The correlation of CQS to PRS was moderate (r = 0.51; P < .001). The correlation was weak for cardiac arrest (r = 0.24; P = .07), weak for sepsis (ρ = 0.45; P < .001) and seizure (ρ = 0.43; P = .001), and strong for teamwork (ρ = 0.71; P < .001). Conclusions and Relevance This multicenter study noted significant differences in the quality of simulated pediatric resuscitative care across a spectrum of EDs. The CQS was higher in PEDs compared with GEDs. However, when controlling for pediatric patient volume and other variables in a multivariable model, PED status does not explain a higher CQS while pediatric patient volume does. The correlation of the PRS was moderate for simulation-based measures of quality.

Disparities in Adherence to Pediatric Sepsis Guidelines across a Spectrum of Emergency Departments: A Multicenter, Cross-Sectional Observational In Situ Simulation Study

BACKGROUND Each year in the United States, 72,000 pediatric patients develop septic shock, at a cost of

Comparing practice patterns between pediatric and general emergency medicine physicians: A scoping review

4.8 billion. Adherence to practice guidelines can significantly reduce mortality; however, few methods to compare performance across a spectrum of emergency departments (EDs) have been described. OBJECTIVES We employed standardized, in situ simulations to measure and compare adherence to pediatric sepsis guidelines across a spectrum of EDs. We hypothesized that pediatric EDs (PEDs) would have greater adherence to the guidelines than general EDs (GEDs). We also explored factors associated with improved performance. METHODS This multi-center observational study examined in situ teams caring for a simulated infant in septic shock. The primary outcome was overall adherence to the pediatric sepsis guideline as measured by six subcomponent metrics. Characteristics of teams were compared using multivariable logistic regression to describe factors associated with improved performance. RESULTS We enrolled 47 interprofessional teams from 24 EDs. Overall, 21/47 teams adhered to all six sepsis metrics (45%). PEDs adhered to all six metrics more than GEDs (93% vs. 22%; difference 71%, 95% confidence interval [CI] 43-84). Adherent teams had significantly higher Emergency Medical Services for Children readiness scores, MD composition of physicians to total team members, teamwork scores, provider perceptions of pediatric preparedness, and provider perceptions of sepsis preparedness. In a multivariable regression model, only greater composite team experience had greater adjusted odds of achieving an adherent sepsis score (adjusted odds ratio 1.38, 95% CI 1.01-1.88). CONCLUSIONS Using standardized in situ scenarios, we revealed high variability in adherence to the pediatric sepsis guideline across a spectrum of EDs. PEDs demonstrated greater adherence to the guideline than GEDs; however, in adjusted analysis, only composite team experience level of the providers was associated with improved guideline adherence.

An Analysis of the Daily Work-Rounding Process in a Pediatric Intensive Care Unit.

Objective Acutely ill infants and children presenting to the emergency department are treated by either physicians with pediatric emergency medicine (PEM) training or physicians without PEM training, a good proportion of which are general emergency medicine–trained physicians (GEDPs). This scoping review identified published literature comparing the care provided to infants and children (⩽21 years of age) by PEM-trained physicians to that provided by GEDPs. Methods The search was conducted in 2 main steps as follows: (1) initial literature search to identify available literature with evolving feedback from the group while simultaneously deciding search concepts as well as inclusion and exclusion criteria and (2) modification of search concepts and conduction of search using finalized concepts as well as review and selection of articles for final analysis using set inclusion criteria. Each study was independently assessed by 2 reviewers for eligibility and quality. Data were independently abstracted by reviewers, and authors were contacted for missing data. Results Our search yielded 3137 titles and abstracts. Twenty articles reporting 19 studies were included in the final analysis. The studies were grouped under type of care, diagnostic studies, medication administration, and process of care. The studies addressed differences in the management of fever, croup, bronchiolitis, asthma, urticaria, febrile seizures, and diabetic ketoacidosis. Conclusions This review highlights the lack of robust studies and heterogeneity of literature comparing practice patterns of PEM-trained physicians with GEDPs. We have outlined a systematic approach to reviewing a body of literature for topics that lack clear terms of comparison across studies.

Using Pleth Variability as a Triage Tool for Children With Obstructive Airway Disease in a Pediatric Emergency Department.

Objective: To complete an objective analysis of the activities that occur during the course of daily rounds in a high acuity academic tertiary care pediatric intensive care unit (PICU). Design: Prospective observational work sampling design. Setting: Tertiary care academic Childrens Hospital Pediatric Intensive Care Unit. Subjects: Multidisciplinary PICU teams. Interventions: None. Methods: Intensive care unit rounds were observed as part of an initiative to improve efficiency over a 2-month period. The number of observations required was determined by Neibels work sampling method. Rounds were broken into various constituent events and then later classified as “value-added/essential,” “value-added/nonessential,” and “nonessential” based on whether the observed event was essential to the core mission of PICU rounds. Results: The mean time spent per patient for all observed teams was 17.9 min (SD 1.3 min). Teams spent 64% of their time doing value-added/essential tasks (11.2 min, SD 2.2 min) and 13% of their time doing value-added/nonessential tasks (2.4 min, SD 0.9 min). Teams spent 23% of their time on non–value-added activities (4.1 min, SD 2.3 min). The top three non–value-added activities conducted during rounds were travel, waiting, and interruptions regarding care of other patients. Given the consistency of time spent on value-added activities among attendings, these non–value-added activities might explain the significant variability observed among attendings in total time spent rounding. Conclusions: This was an observational study to characterize the activities that occur during the course of a routine PICU work rounds. Although there was significant consistency in the time spent per patient in value-added activities, there was significant disparity in time spent on nonessential activities, such as travel and waiting. A dedicated attempt to reduce time spent on nonessential activities can substantially reduce rounding times and improve the efficiency and value of rounds.

Neonatal Intubation Competency Assessment Tool: Development and Validation

Objectives Patients with obstructive airway disease have varying degrees of pulsus paradoxus that correlate with illness severity. Pulsus paradoxus can be measured using plethysmography. We investigated whether plethysmograph (pleth) variability on admission to the pediatric emergency department (ED) could predict patient disposition. We hypothesized that patients with a larger pleth variability would have a higher likelihood of being admitted to a general pediatrics unit or the intensive care unit (ICU). Methods We conducted a prospective single-center study of children aged 1 to 18 years who presented to a pediatric ED with a diagnosis of asthma or reactive airway disease. The pleth variability index (PVI) was calculated from their initial plethysmography tracing. Disposition from the ED was recorded as discharge, admission to the floor, or admission to the ICU. Results A total of 117 patients were included in our study. Forty-eight patients were discharged home, 61 were admitted to the floor, and 8 were admitted to the ICU. The median PVI for each of these groups was 0.27 (interquartile range [IQR], 0.19–0.39) for discharges, 0.29 (IQR, 0.20–0.44) for patients admitted to the floor, and 0.56 (IQR, 0.35–0.70) for patients admitted to the ICU. A Kruskal-Wallis test demonstrated a significant difference in the PVI between each of the groups (P = 0.0087). Conclusions Our results suggest that PVI may be a useful tool in the triage of children who present to the ED with obstructive airway disease. Further studies should aim to assess the validity of PVI in predicting the response to bronchodilator therapy during the course of a patients hospitalization.

Effect of Location on Tracheal Intubation Safety in Cardiac Disease—Are Cardiac ICUs Safer?

BACKGROUND Neonatal tracheal intubation (NTI) is an important clinical skill. Suboptimal performance is associated with patient harm. Simulation training can improve NTI performance. Improving performance requires an objective assessment of competency. Competency assessment tools need strong evidence of validity. We hypothesized that an NTI competency assessment tool with multisource validity evidence could be developed and be used for formative and summative assessment during simulation-based training. METHODS An NTI assessment tool was developed based on a literature review. The tool was refined through 2 rounds of a modified Delphi process involving 12 subject-matter experts. The final tool included a 22-item checklist, a global skills assessment, and an entrustable professional activity (EPA) level. The validity of the checklist was assessed by having 4 blinded reviewers score 23 videos of health care providers intubating a neonatal simulator. RESULTS The checklist items had good internal consistency (overall α = 0.79). Checklist scores were greater for providers at greater training levels and with more NTI experience. Checklist scores correlated with global skills assessment (ρ = 0.85; P < .05), EPA levels (ρ = 0.87; P < .05), percent glottic exposure (r = 0.59; P < .05), and Cormack-Lehane scores (ρ = 0.95; P < .05). Checklist scores reliably predicted EPA levels. CONCLUSIONS We developed an NTI competency assessment tool with multisource validity evidence. The tool was able to discriminate NTI performance based on experience. The tool can be used during simulation-based NTI training to provide formative and summative assessment and can aid with entrustment decisions.

1070: USING PLETH VARIABILITY INDEX TO ASSESS THE COURSE OF ILLNESS IN CHILDREN WITH ASTHMA

Objectives: Evaluate differences in tracheal intubation–associated events and process variances (i.e., multiple intubation attempts and oxygen desaturation) between pediatric cardiac ICUs and noncardiac PICUs in children with underlying cardiac disease. Design: Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children). Setting: Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016. Patients: Children with medical or surgical cardiac disease who underwent intubation in an ICU. Interventions: None. Measurements and Main Results: Our primary outcome was the rate of any adverse tracheal intubation–associated event. Secondary outcomes were severe tracheal intubation–associated events, multiple tracheal intubation attempt rates, and oxygen desaturation. There were 1,502 tracheal intubations in children with underlying cardiac disease (751 in cardiac ICUs, 751 in noncardiac ICUs) reported. Cardiac ICUs and noncardiac ICUs had similar proportions of patients with surgical cardiac disease. Patients undergoing intubation in cardiac ICUs were younger (median age, 1 mo [interquartile range, 0–6 mo]) compared with noncardiac ICUs (median 3 mo [interquartile range, 1–11 mo]; p < 0.001). Tracheal intubation–associated event rates were not different between cardiac ICUs and noncardiac ICUs (16% vs 19%; adjusted odds ratio, 0.74; 95% CI, 0.54–1.02; p = 0.069). However, in a sensitivity analysis comparing cardiac ICUs with mixed ICUs (i.e., ICUs caring for children with either general pediatric or cardiac diseases), cardiac ICUs had decreased odds of adverse events (adjusted odds ratio, 0.71; 95% CI, 0.52–0.97; p = 0.033). Rates of severe tracheal intubation–associated events and multiple attempts were similar. Desaturations occurred more often during intubation in cardiac ICUs (adjusted odds ratio, 1.61; 95% CI, 1.04–1.15; p = 0.002). Conclusions: In children with underlying cardiac disease, rates of adverse tracheal intubation–associated events were not lower in cardiac ICUs as compared to noncardiac ICUs, even after adjusting for differences in patient characteristics and care models.

1209: SAFETY THREATS RELATED TO DEXTROSE ADMINISTRATION IN A SIMULATED PEDIATRIC PATIENT WITH SEIZURE

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) 165 (54.8%); GOLD 3: 96 (31.9%). During 2-year follow-up, 26 patients were admitted to the ICU. Age (yrs): 67.7 ± 10.3 female sex: 4 (15.4%); pack-years: 43.6 ± 22.8; GOLD 1: 3 (11.5%); GOLD 2: 19 (73.1%); GOLD 3: 4 (15.4%). Admission diagnosis: medical 14 (53.8%); planned surgical 10 (38.5%) and emergency surgical 2 (7.7%). General population. Age (yrs): 64; female sex: 40%. Admission diagnosis: medical 50.5%; planned surgical 37.2% and emergency surgical 12.3%. ICU admission rates COPD patients vs general population: 8.6% vs 0.5%, p< 0.001, OR 18.8. Subgroup analyses: GOLD 1 7.5%, p=0.002, OR 16.0, GOLD 2 11.5%, p<0.001, OR 25.8, GOLD 3 4.2%, p=0.003, OR 8.6. Conclusions: ICU admission rates were significantly higher in patients with COPD compared to the general population.

Use of an Arterial Cannula in Intubated Children Secondary to Bronchiolitis is Associated with Multiple Blood Gas Sampling and Prolonged Ventilation

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) (32% vs. 0%, p=0.001), walking inside room (30% vs. 0%, p=0.001), and OT activities (writing, 80% vs. 38%, p=0.001). The recall of actual PT activities was similar between CAM-ICU positive and negative patients (>50% match, 27% vs. 38%, p=0.44), whereas CAM-ICU positive patients recalled less OT activities (>50% match, 19% vs. 52%, p=0.01). Conclusions: CAM-ICU positive MV patients have worse PT and OT performances and less recall of their activities during EM. Delirium in MV ICU patients is associated with worse level of activities and memory impairment. Tailoring EM sessions for CAM-ICU positive patients is needed to improve both physical and memory activities.