Sandeep Tripathi

Implementation of patient-centered bedside rounds in the pediatric intensive care unit.

Implementation of effective family-centered rounds in an intensive care unit environment is fraught with challenges. We describe the application of PDSA (Plan, Do, Study, Act) cycles in a quality improvement project to improve the process of rounds and increase family participation and provider satisfaction. We conducted pre-/postintervention surveys and used 5 process measures for a total of 1296 daily patient rounds over 7 months. We were successful in conducting family-centered rounds for 90% of patients, with 40% family participation and a 64.6% satisfactory rating by pediatric intensive care unit providers.

Plan to Have No Unplanned: A Collaborative, Hospital-Based Quality-Improvement Project to Reduce the Rate of Unplanned Extubations in the Pediatric ICU

BACKGROUND: Although under-reported and understudied, unplanned extubations carry a significant risk of patient harm and even death. They are an important yardstick of quality control of care of intubated patients in the ICU. A unit-based risk assessment and multidisciplinary approach is required to decrease the incidence of unplanned extubations. METHODS: As part of a quality-improvement initiative of Childrens Hospital at Montefiore, all planned and unplanned extubations in a multidisciplinary 20-bed pediatric ICU were evaluated over a 12-month period (January to December 2010). At the end of 6 months, an interim analysis was performed, and high-risk patient groups and patient care factors were identified. These factors were targeted in the second phase of the project. RESULTS: Over this period, there were a total of 267 extubations, of which 231 (87%) were planned extubations and 36 (13%) were unplanned. A patient care policy targeting the risk factors was instituted, along with extensive nursing and other personnel education in the second phase. As a result of this intervention, the unplanned extubation rate in the pediatric ICU decreased from 3.55 to 2.59/100 intubation days. All subjects who had an unplanned extubation during nursing procedures or transport required re-intubation, whereas none of the unplanned extubations during ventilator weaning required re-intubation. CONCLUSIONS: A targeted approach based on unit-specific risk factors is most effective in quality-improvement projects. A specific policy for sedation and weaning can be very helpful in managing intubated patients and preventing unintended harm.

Overcoming Barriers to Delirium Screening in the Pediatric Intensive Care Unit

BACKGROUND Delirium is associated with poor outcomes in adults but is less extensively studied in children. OBJECTIVES To describe a quality improvement initiative to implement delirium assessment in a pediatric intensive care unit and to identify barriers to delirium screening completion. METHODS A survey identified perceived barriers to delirium assessment. Failure modes and effects analysis characterized factors likely to impede assessment. A randomized case‐control study evaluated factors affecting assessment by comparing patients always assessed with patients never assessed. RESULTS Delirium assessment was completed in 57% of opportunities over 1 year, with 2% positive screen results. Education improved screening completion by 20%. Barriers to assessment identified by survey (n = 25) included remembering to complete assessments, documentation outside workflow, and “busy patient.” Factors with high risk prediction numbers were lack of time and paper charting. Patients always assessed had more severe illness (median Pediatric Index of Mortality 2 score, 0.90 vs 0.36; P < .001), more developmental disabilities (moderate to severe pediatric cerebral performance category score, 54% vs 32%; P = .007), and admission during lower pediatric intensive care unit census (median [interquartile range], 10 [9‐12] vs 12 [10‐13]; P < .001) than did those never assessed (each group, n = 80). Patients receiving mechanical ventilation were less likely to be assessed (41.0% vs 51.2%, P < .001). CONCLUSIONS Successful implementation of pediatric delirium screening may be associated with early use of quality improvement tools to identify assessment barriers, comprehensive education, monitoring system with feedback, multidisciplinary team involvement, and incorporation into nursing workflow models.

813: SAFETY AND EFFICACY OF INTRAVENOUS LIDOCAINE IN THE TREATMENT OF ADOLESCENTS WITH STATUS MIGRAINE

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Migraine headaches are common in children and occur with increasing frequency through adolescence. To date there does not appear to be any published studies evaluating the use of IV lidocaine in children and adolescents with status migraine. The objective of this study is to evaluate the safety and efficacy of IV lidocaine in treating children and adolescents with status migraine. Methods: A retrospective review of patients admitted to the PICU who received IV lidocaine for the treatment of status migraine during the period of 3/21/2014 to 3/14/2016, was conducted. Patients with a non-headache variant of migraine and those older than 19 years of age were excluded from analysis. Results: A total of 33 lidocaine infusions were administered to patients with status migraine. Two patients were excluded from analysis. Patient’s age ranged from 10 to 19 years with an average of 14.9 ± 2.4 years. Mean duration of hospitalization was 4.6 ± 1.5 days. 25% of patients had failed DHE management prior to IV lidocaine during the same hospitalization. 29% of cases had received IV lidocaine in the past. All cases underwent neurology consult. Prior to administration of IV lidocaine, all first time patients underwent ECHO, ECG and cardiology consults. Also, all patients were admitted to the PICU and underwent continuous cardiorespiratory monitoring while receiving IV lidocaine. Lidocaine was administered as a bolus in 80% of the patients, followed by an infusion which was initiated at a mean rate of 1.29 ± 0.2 mg/ kg/hr and a max mean rate of 1.56 ± 0.27 mg/kg/hr. All lidocaine boluses were administered over 90 minutes. The highest lidocaine infusion was 2.25 mg/kg/hr and lowest 1.125 mg/kg/hr. Lidocaine was very well tolerated with interruption in only one patient for side effects: chest pain and anxiety. Mean pain score at the time of initiation of lidocaine was 4.4 ± 2.4. On an average it took 16.3 ± 12.9 hrs for a 50% reduction in pain and 19.3 ± 19.3 hrs for complete resolution. 90% of cases experienced pain resolution with 51% encountering a relapse of pain after resolution. Mean pain score at the time of discharge was 1 ± 1.6. Both mean reported highest and lowest scores dropped over the course of the 5 days from 5.1 ± 1.9 and 2.1 ± 2.4 on day 1 to 1.0 ± 1.4 and 0 on day 5 of therapy. One-way analysis by ANOVA for high pain score by day was statistically significant with a p value of < 0.01. Conclusions: Intravenous lidocaine maybe a safe and effective treatment for children and adolescents with status migraine

Effects of enteral nutrition on clinical outcomes among mechanically ventilated and sedated patients in the pediatric intensive care unit

Objective. To analyze the effects of enteral nutrition on outcomes and complications of critically ill children in the pediatric in-tensive care unit (PICU).Design. Retrospective cohort study. Setting. PICU in a tertiary care academic medical center.Patients. Patients up to age 17 years who were admitted to the PICU between Janu-ary 1, 2011, and December 31, 2013. Interventions. Intubation for more than 48 hours and requiring any sedative medica-tions. Patients with surgical contraindica-tions to feeding were excluded. Measures and Main Results. A total of 165 patients met inclusion criteria. Both manual review of the electronic health re-cord and automated data capture (when-ever technically feasible) were conducted. Data were collected in REDCap software and analyzed using a statistical discovery program. The mean (SD) calorie intake within the first 10 days of PICU admission was 40% (31.9%) of the prescribed calo-ries. Only 67% of the patients had feeding initiated within 48 hours of admission. No significant difference in hospital or PICU length of stay or ventilator-free days was observed in patients who met one-third of their nutritional goals (50.3%) compared with patients who did not (49.7%). Mor-tality was nonsignificantly higher among patients who did not meet nutritional goals (P=.07). No association was found between higher doses of opioids or benzo-diazepines and nutrition tolerance or gas-trointestinal complications. Conclusions. Early adequate enteral nutri-tion had no statistically significant impact on the short-term clinical outcomes of PICU patients.

913: DESIGN AND WORLDWIDE PILOT OF A WEB-BASED, REAL TIME PEDIATRIC CRITICAL CARE DECISION SUPPORT TOOL

Learning Objectives: Incomplete knowledge and adherence to best practices in critical illness often leads to complications and poor outcomes. Creation of an international collaborative using a Quality Improvement approach (Checklist for Early Recognition and Treatment of Acute Illness and Injury in Pediatrics, CERTAINp) can facilitate timely and improved best practice delivery in countries with limited local resources and training in pediatric intensive care. Methods: A web-based platform was created using cognitive and ergonomic principles and integrated into the daily unit workflow to facilitate high quality, high value healthcare behaviors. 6172 pediatric critical care providers were contacted using World Federation of Pediatric and Intensive Care Societies listserv, with 78 PICUs across 34 countries responding (1.3%). 52% PICUs were classified as belonging to Low and Middle Income countries based on the World Bank Classification. 12/35 centers were recruited for this study. 5 centers are currently involved in baseline data collection phase with 2 centers entering the training phase. 183 decision support cards were designed and reviewed by pediatric critical care experts across the world. Innovative content management, team meetings and remote site co-ordination strategies were utilized using web platforms such as Google docs, Trello, MS Project, etc. Results: Data (demographic, lab, clinical, outcome measures, adherence to guidelines) has been collected on 75 patients from 3 centers with a mean patient age of 4.8 ± 4.9 yr; and ICU Length of Stay of 7 ± 6 days; 59% diagnoses were infection related, commonest being Pneumonia and Malaria; 28-day mortality was 28%. Logistic obstacles operating in 5 countries were time-zone differences, IT infrastructure, regional tropical diseases and varied usage of search engines. To overcome them, mobile and print versions of CERTAINp are being developed. Newer syndrome cards are frequently added. Conclusions: Requirement and opportunities exist for multi-center trials in developing countries. Adaptable research design and utilization of IT resources can overcome the barriers.