Sharon Kinney

Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results

Aims: To determine the impact of a paediatric medical emergency team (MET) on cardiac arrest, mortality, and unplanned admission to intensive care in a paediatric tertiary care hospital. Methods: Comparison of the retrospective incidence of cardiac arrest and death during 41 months before introduction of a MET service with the prospective incidence of these events during 12 months after its introduction. Comparison of transgression of MET call criteria in patients who arrested and died before and after introduction of MET. Results: Cardiac arrest decreased from 20 among 104 780 admissions (0.19/1000) to 4 among 35 892 admissions (0.11/1000) (risk ratio 1.71, 95% CI 0.59 to 5.01), while death decreased from 13 (0.12/1000) to 2 (0.06/1000) during these periods (risk ratio 2.22, 95% CI 0.50 to 9.87). Unplanned admissions to intensive care increased from 20 (SD 6) to 24 (SD 9) per month. The incidence of transgression of MET call criteria in patients who arrested decreased from 17 to 0 (risk difference 0.16/1000, 95% CI 0.09 to 0.24), and in those who died, decreased from 12 to 0 (risk difference 0.11/1000, 95% CI 0.05 to 0.18) after introduction of MET. Conclusions: Introduction of a medical emergency team service was coincident with a reduction of cardiac arrest and mortality and a slight increase in admissions to intensive care.

Reduction of hospital mortality and of preventable cardiac arrest and death on introduction of a pediatric medical emergency team.

Objective: To determine the effect of a medical emergency team (MET) on the incidence of unexpected cardiac arrest and death. Design: Comparison of retrospective data (pre-MET) before introduction of MET with prospective data after introduction of MET system (post-MET). Setting: Tertiary care pediatric hospital. Patients: A total of 104,780 admissions during a 41-month period pre-MET; 138,424 admissions during 48 months post-MET. Interventions: Introduction of a MET. Results: Total hospital deaths decreased from 4.38 to 2.87/1000 admissions (risk ratio 0.65, 95% confidence interval [CI] 0.57–0.75, p < 0.0001). Ward unexpected death decreased from 13 (0.12/1000) to 6 (0.04/1000) (risk ratio 0.35, 95% CI 0.13–0.92, p = 0.03) but unexpected cardiac arrests did not change from 0.19/1000 to 0.17/1000 (risk ratio 0.91, 95% CI 0.50–1.64, p = 0.75). Thirty-four hospital deaths, including three unexpected deaths (1 out of 72 MET calls), were prevented each year of MET operation. Preventable cardiac arrest (children whose symptoms or signs fulfilled MET calling criteria) decreased from 17 (0.16/1000) to 10 (0.07/1000) (risk ratio 0.45, 95% CI 0.20–0.97, p = 0.04) and in whom death decreased from 12 to 2 (0.11/1000 to 0.01/1000) (risk ratio 0.13, 95% CI 0.03–0.56, p = 0.001). Nonpreventable cardiac arrest (children whose symptoms or signs did not fulfill MET calling criteria) increased from 3 to 14 (0.03/1000 to 0.10/1000, p = 0.03) but death did not increase. Survival from cardiac arrest increased from 7 of 20 patients to 17 of 23 (risk ratio 2.11, 95% CI 1.11–4.02, p = 0.01). Annual calls for urgent assistance were 202 in the post-MET era and 46 during the pre-MET era (ratio 4.4:1). Conclusions: Introduction of a MET was associated with reduction of total hospital death and reduction of preventable cardiac arrest and death with increased survival in wards of a pediatric hospital. MET calling criteria identified some but not all children at risk of unexpected cardiac arrest and death.

Attitudes and barriers to a Medical Emergency Team system at a tertiary paediatric hospital

AIM To determine the attitudes and barriers to an established paediatric Medical Emergency Team (MET) system among nurses and doctors. METHODS Invitation to all clinical staff in a paediatric hospital to complete an electronic 41-item branched survey. Responses were graded on a Likert scale. RESULTS 407 staff completed the survey (280 nurses, 127 doctors). The MET system was highly valued for obtaining urgent assistance for the seriously ill patients by 85% of nurses and 83% of doctors. However, barriers to MET activation included; preference to contact the covering (attending) doctors by 80% of nurses and 45% of doctors, active discouragement to activating a MET by 41% of nurses and 12% of doctors, and fear of criticism by 17% of nurses and 9% of doctors if the patient was not deemed seriously ill by the MET attendees. Less experienced staff were significantly more likely to report barriers to calling a MET. Negative attitudes from MET attendees were reported by nurses (24%) and doctors (6.5%). Failure to recognize serious illness was revealed by unwillingness of 47% of doctors and 32% of nurses to activate MET when activation criteria were attained and by retrospective realization by 30% of doctors and 15% of nurses that they had failed to activate MET when needed. CONCLUSIONS Cultural and behavioral barriers to MET activation and inability to recognize serious illness may explain in part the failure of a MET system to completely eliminate unexpected cardiac arrest and death. Unless these issues are addressed, the full benefits of a MET system may not be realised.

An analysis of the efficacy of bag-valve-mask ventilation and chest compression during different compression-ventilation ratios in manikin-simulated paediatric resuscitation

The ideal chest compression and ventilation ratio for children during performance of cardiopulmonary resuscitation (CPR) has not been determined. The efficacy of chest compression and ventilation during compression ventilation ratios of 5:1, 10:2 and 15:2 was examined. Eighteen nurses, working in pairs, were instructed to provide chest compression and bag-valve-mask ventilation for 1 min with each ratio in random on a child-sized manikin. The subjects had been previously taught paediatric CPR within the last 3 or 5 months. The efficacy of ventilation was assessed by measurement of the expired tidal volume and the number of breaths provided. The rate of chest compression was guided by a metronome set at 100/min. The efficacy of chest compressions was assessed by measurement of the rate and depth of compression. There was no significant difference in the mean tidal volume or the percentage of effective chest compressions delivered for each compression-ventilation ratio. The number of breaths delivered was greatest with the ratio of 5:1. The percentage of effective chest compressions was equal with all three methods but the number of effective chest compressions was greatest with a ratio of 5:1. This study supports the use of a compression-ventilation ratio of 5:1 during two-rescuer paediatric cardiopulmonary resuscitation.

Reducing hospital-acquired infections and improving the rational use of antibiotics in a developing country: an effectiveness study

Background Prevention of hospital-acquired infections (HAI) is central to providing safe and high quality healthcare. Transmission of infection between patients by health workers, and the irrational use of antibiotics have been identified as preventable aetiological factors for HAIs. Few studies have addressed this in developing countries. Aims To implement a multifaceted infection control and antibiotic stewardship programme and evaluate its effectiveness on HAIs and antibiotic use. Methods A before-and-after study was conducted over 27 months in a teaching hospital in Indonesia. All children admitted to the paediatric intensive care unit and paediatric wards were observed daily. Assessment of HAIs was made based on the criteria from the Centers for Disease Control and Prevention. The multifaceted intervention consisted of a hand hygiene campaign, antibiotic stewardship (using the WHO Pocket Book of Hospital Care for Children guidelines as standards of antibiotic prescribing for community-acquired infections), and other elementary infection control practices. Data were collected using an identical method in the preintervention and postintervention periods. Results We observed a major reduction in HAIs, from 22.6% (277/1227 patients) in the preintervention period to 8.6% (123/1419 patients) in the postintervention period (relative risk (RR) (95% CI) 0.38 (0.31 to 0.46)). Inappropriate antibiotic use declined from 43% (336 of 780 patients who were prescribed antibiotics) to 20.6% (182 of 882 patients) (RR 0.46 (0.40 to 0.55)). Hand hygiene compliance increased from 18.9% (319/1690) to 62.9% (1125/1789) (RR 3.33 (2.99 to 3.70)). In-hospital mortality decreased from 10.4% (127/1227) to 8% (114/1419) (RR 0.78 (0.61 to 0.97)). Conclusions Multifaceted infection control interventions are effective in reducing HAI rates, improving the rational use of antibiotics, increasing hand hygiene compliance, and may reduce mortality in hospitalised children in developing countries.

Clinical profile of hospitalized children provided with urgent assistance from a medical emergency team.

OBJECTIVE. The purpose of this work was to describe the frequency, characteristics, and outcomes of critical events and hospitalized children requiring medical emergency team review. PATIENTS AND METHODS. We conducted an audit of prospectively collected medical emergency team forms and a retrospective review of medical charts during an 18-month period at a tertiary pediatric hospital in Australia. Critical events were defined as cardiac arrest, endotracheal intubation on the ward, reversal of analgesia or sedation, fluid resuscitation at ≥40 mL/kg, hyponatremia (serum sodium level of ≤125 mmol/L), hypernatremia (serum sodium level of ≥155 mmol/L), hypoglycemia (glucose level of ≤2 mmol/L), or severe metabolic acidosis (pH ≤ 7.1). RESULTS. A total of 172 children had 225 medical emergency team calls (10.6 calls per 1000 hospital admissions and 2.0 calls per 1000 patient-days). Forty-two percent of calls were for infants <1 year old. Preexisting chronic disease was common, with 20% having a chronic underlying neurologic disorder. Forty-four percent of the children were postoperative. The mortality rate of the 172 children was 7.6% in the hospital and 13.4% within 1 year. Thirty-three children had a critical event, with reversal of analgesia being the most common event (n = 11). Postoperative children were more frequently seen in the critical-event group (64% vs 40%). Hospital and 1-year mortality rates were higher for children who had a critical event (16.1% vs 22.6%, respectively) than those who did not (5.7% vs 11.3%). CONCLUSIONS. Chronic and complex illnesses were prevalent among children provided with urgent medical assistance from the medical emergency team in a tertiary hospital. Children in the postoperative phase were overrepresented among those with a critical event. A critical event significantly increased the risk of hospital mortality. Greater knowledge of high-risk groups is required to further improve outcomes for hospitalized children.

Medication errors in hospitalised children

This study aims to explore the characteristics of reported medication errors occurring among children in an Australian childrens hospital, and to examine the types, causes and contributing factors of medication errors.

Interventions to Reduce Medication Errors in Pediatric Intensive Care

Objective: To systematically examine the research literature to identify which interventions reduce medication errors in pediatric intensive care units. Data Sources: Databases were searched from inception to April 2014. Study Selection and Data Extraction: Studies were included if they involved the conduct of an intervention with the intent of reducing medication errors. Data Synthesis: In all, 34 relevant articles were identified. Apart from 1 study, all involved single-arm, before-and-after designs without a comparative, concurrent control group. A total of 6 types of interventions were utilized: computerized physician order entry (CPOE), intravenous systems (ISs), modes of education (MEs), protocols and guidelines (PGs), pharmacist involvement (PI), and support systems for clinical decision making (SSCDs). Statistically significant reductions in medication errors were achieved in 7/8 studies for CPOE, 2/5 studies for ISs, 9/11 studies for MEs, 1/2 studies for PGs, 2/3 studies for PI, and 3/5 studies for SSCDs. The test for subgroup differences showed that there was no statistically significant difference among the 6 subgroups of interventions, χ2(5) = 1.88, P = 0.87. The following risk ratio results for meta-analysis were obtained: CPOE: 0.47 (95% CI = 0.28, 0.79); IS: 0.37 (95% CI = 0.19, 0.73); ME: 0.36 (95% CI = 0.22, 0.58); PG: 0.82 (95% CI = 0.21, 3.25); PI: 0.39 (95% CI = 0.10, 1.51), and SSCD: 0.49 (95% CI = 0.23, 1.03). Conclusions: Available evidence suggests some aspects of CPOE with decision support, ME, and IS may help in reducing medication errors. Good quality, prospective, observational studies are needed for institutions to determine the most effective interventions.

Hyponatraemia and seizures in oncology patients associated with hypotonic intravenous fluids

Hyponatraemia is a frequent cause of morbidity in hospitalized children.1 There have been numerous case reports of hyponatraemia, seizures, cerebral oedema and death occurring in association with administration of excessive free water in children with infective and surgical conditions. Such cases have often involved the use of large volumes of hypotonic i.v. fluids, particularly 0.18% sodium chloride (NaCl); 0.18% NaCl is used in hydration protocols in many paediatric cancer units. We report three cases of seizures and neurological deterioration associated with hyponatraemia among children being treated for cancer. The cases occurred over a 1 year period between June 2003 and June 2004, and can be seen as sentinel events. We suggest approaches to preventing these complications.

Prevention of nosocomial infections in developing countries, a systematic review.

Abstract Background: Prevention of nosocomial infection is key to providing good quality, safe healthcare. Infection control programmes (hand-hygiene campaigns and antibiotic stewardship) are effective in reducing nosocomial infections in developed countries. However, the effectiveness of these programmes in developing countries is uncertain. Objective: To evaluate the effectiveness of interventions for preventing nosocomial infections in developing countries. Methods: A systematic search for studies which evaluated interventions to prevent nosocomial infection in both adults and children in developing countries was undertaken using PubMed. Only intervention trials with a randomized controlled, quasi-experimental or sequential design were included. Where there was adequate homogeneity, a meta-analysis of specific interventions was performed using the Mantel–Haenzel fixed effects method to estimate the pooled risk difference. Results: Thirty-four studies were found. Most studies were from South America and Asia. Most were before-and-after intervention studies from tertiary urban hospitals. Hand-hygiene campaigns that were a major component of multifaceted interventions (18 studies) showed the strongest effectiveness for reducing nosocomial infection rates (median effect 49%, effect range 12·7–100%). Hand-hygiene campaigns alone and studies of antibiotic stewardship to improve rational antibiotic use reduced nosocomial infection rates in three studies [risk difference (RD) of −0·09 (95%CI −0·12 to −0·07) and RD of −0·02 (95%CI −0·02 to −0·01), respectively]. Conclusions: Multifaceted interventions including hand-hygiene campaigns, antibiotic stewardship and other elementary infection control practices are effective in developing countries. The modest effect size of hand-hygiene campaigns alone and negligible effect size of antibiotic stewardship reflect the limited number of studies with sufficient homogeneity to conduct meta-analyses.