Tom B. Rice

Decreasing PICU Catheter-Associated Bloodstream Infections: NACHRI's Quality Transformation Efforts

OBJECTIVE: Despite the magnitude of the problem of catheter-associated bloodstream infections (CA-BSIs) in children, relatively little research has been performed to identify effective strategies to reduce these complications. In this study, we aimed to develop and evaluate effective catheter-care practices to reduce pediatric CA-BSIs. STUDY DESIGN AND METHODS: Our study was a multi-institutional, interrupted time-series design with historical control data and was conducted in 29 PICUs across the United States. Two central venous catheter–care practice bundles comprised our intervention: the insertion bundle of pediatric-tailored care elements derived from adult efforts and the maintenance bundle derived from the Centers for Disease Control and Prevention recommendations and expert pediatric clinician consensus. The bundles were deployed with quality-improvement teaching and methods to support their adoption by teams at the participating PICUs. The main outcome measures were the rate of CA-BSIs from January 2004 to September 2007 and compliance with each element of the insertion and maintenance bundles from October 2006 to September 2007. RESULTS: Average CA-BSI rates were reduced by 43% across 29 PICUs (5.4 vs 3.1 CA-BSIs per 1000 central-line-days; P < .0001). By September 2007, insertion-bundle compliance was 84% and maintenance-bundle compliance was 82%. Hierarchical regression modeling showed that the only significant predictor of an observed decrease in infection rates was the collective use of the insertion and maintenance bundles, as demonstrated by the relative rate (RR) and confidence intervals (CIs) (RR: 0.57 [95% CI: 0.45–0.74]; P < .0001). We used comparable modeling to assess the relative importance of the insertion versus maintenance bundles; the results showed that the only significant predictor of an infection-rate decrease was maintenance-bundle compliance (RR: 0.41 [95% CI: 0.20–0.85]; P = .017). CONCLUSIONS: In contrast with adult ICU care, maximizing insertion-bundle compliance alone cannot help PICUs to eliminate CA-BSIs. The main drivers for additional reductions in pediatric CA-BSI rates are issues that surround daily maintenance care for central lines, as defined in our maintenance bundle. Additional research is needed to define the optimal maintenance bundle that will facilitate elimination of CA-BSIs for children.

Extubation failure in pediatric intensive care: A multiple-center study of risk factors and outcomes

ObjectiveTo determine a contemporary failed extubation rate, risk factors, and consequences of extubation failure in pediatric intensive care units (PICUs). Three hypotheses were investigated: a) Extubation failure is in part disease specific; b) preexisting respiratory conditions predispose to extubation failure; and c) admission acuity scoring does not affect extubation failure. DesignTwelve-month prospective, observational, clinical study. SettingSixteen diverse PICUs in the United States. PatientsPatients were 2,794 patients from the newborn period to 18 yrs of age experiencing a planned extubation trial. InterventionsNone. Measurements and Main ResultsA descriptive statistical analysis was performed, and outcome differences of the failed extubation population were determined. The extubation failure rate was 6.2% (174 of 2,794; 95% confidence interval, 5.3–7.1). Patient features associated with extubation failure (p < .05) included age ≤24 months; dysgenetic condition; syndromic condition; chronic respiratory disorder; chronic neurologic condition; medical or surgical airway condition; chronic noninvasive positive pressure ventilation; the need to replace the endotracheal tube on admission to the PICU; and the use of racemic epinephrine, steroids, helium-oxygen therapy (heliox), or noninvasive positive pressure ventilation within 24 hrs of extubation. Patients failing extubation had longer pre-extubation intubation time (failed, 148.7 hrs, sd ± 207.8 vs. success, 107.9 hrs, sd ± 171.3; p < .001), longer PICU length of stay (17.5 days, sd ± 15.6 vs. 7.6 days, sd ± 11.1; p < .001), and a higher mortality rate than patients not failing extubation (4.0% vs. 0.8%; p < .001). Failure was found to be in part disease specific, and preexisting respiratory conditions were found to predispose to failure whereas admission acuity did not. ConclusionA variety of patient features are associated with an increase in extubation failure rate, and serious outcome consequences characterize the extubation failure population in PICUs.

Reducing PICU Central Line–Associated Bloodstream Infections: 3-Year Results

OBJECTIVES: To evaluate the long-term impact of pediatric central line care practices in reducing PICU central line–associated bloodstream infection (CLA-BSI) rates and to evaluate the added impact of chlorhexidine scrub and chlorhexidine-impregnated sponges. METHODS: A 3-year, multi-institutional, interrupted time-series design (October 2006 to September 2009), with historical control data, was used. A nested, 18-month, nonrandomized, factorial design was used to evaluate 2 additional interventions. Twenty-nine PICUs were included. Two central line care bundles (insertion and maintenance bundles) and 2 additional interventions (chlorhexidine scrub and chlorhexidine-impregnated sponges) were used. CLA-BSI rates (January 2004 to September 2009), insertion and maintenance bundle compliance rates (October 2006 to September 2009), and chlorhexidine scrub and chlorhexidine-impregnated sponge compliance rates (January 2008 to June 2009) were assessed. RESULTS: The average aggregate baseline PICU CLA-BSI rate decreased 56% over 36 months from 5.2 CLA-BSIs per 1000 line-days (95% confidence interval [CI]: 4.4–6.2 CLA-BSIs per 1000 line-days) to 2.3 CLA-BSIs per 1000 line-days (95% CI: 1.9–2.9 CLA-BSIs per 1000 line-days) (rate ratio: 0.44 [95% CI: 0.37–0.53]; P < .0001). No statistically significant differences in CLA-BSI rate decreases between PICUs using or not using either of the 2 additional interventions were found. CONCLUSIONS: Focused attention on consistent adherence to the use of pediatrics-specific central line insertion and maintenance bundles produced sustained, continually decreasing PICU CLA-BSI rates. Additional use of either chlorhexidine for central line entry scrub or chlorhexidine-impregnated sponges did not produce any statistically significant additional reduction in PICU CLA-BSI rates.

Inhaled nitric oxide reduces the utilization of extracorporeal membrane oxygenation in persistent pulmonary hypertension of the newborn

OBJECTIVE To determine if the use of inhaled nitric oxide therapy reduces the need for extracorporeal membrane oxygenation (ECMO) in persistent pulmonary hypertension of the newborn. DESIGN A matched cohort study with retrospective data extraction. SETTING Pediatric and neonatal intensive care units at a medical school-affiliated childrens hospital serving as a regional referral center for respiratory failure. PATIENTS Records of all neonates transferred for rescue therapy for persistent pulmonary hypertension during the study period were analyzed, with inclusion in the study based on defined gas exchange parameters, and with exclusion from the study based on the presence of congenital heart disease, diaphragmatic hernia, or lethal chromosomal abnormality. Assignment to cohorts was based on availability of inhaled nitric oxide therapy: group 1 patients were admitted when inhaled nitric oxide was unavailable; group 2 patients were admitted when inhaled nitric oxide was available. INTERVENTIONS Standard criteria (alveolar-arterial oxygen tension gradient of > 600 torr [> 80 kPa], or oxygenation index of > 40) were used to trigger initial evaluation for ECMO when these criteria were met for 2 hrs, and ECMO was initiated if these criteria continued to be met for 12 hrs, or if cardiovascular instability occurred. Ventilator management in all patients was directed to improve arterial oxygenation, such that ECMO criteria were no longer met. Patients in group 2 only were treated with inhaled nitric oxide after meeting ECMO evaluation criteria, and they continued to receive inhaled nitric oxide if a quantifiable improvement in gas exchange occurred. MEASUREMENTS AND MAIN RESULTS Fifty patients qualified for inclusion in the analysis (29 patients in group 1, and 21 patients in group 2). In group 1, 21 (72%) patients met ECMO criteria, and 16 (76%) patients required ECMO therapy. In group 2, 16 (76%) patients met ECMO criteria, 15 patients received inhaled nitric oxide therapy, and only four (25%) patients required ECMO therapy (p = .003 compared with group 1). Treatment with inhaled nitric oxide resulted in an initial increase in PaO2, without adverse effects, in all of the treated patients. The reduction in ECMO utilization in group 2 was achieved with a higher rate of complication-free survival (survival without oxygen, requirement at 28 days, p = .018; survival without intracranial hemorrhage, p = .048), and a lower hospital cost per survivor (p = .021), compared with group 1 patients. CONCLUSION In neonates with persistent pulmonary hypertension, therapy with inhaled nitric oxide reliably and safely improves oxygenation, thereby resulting in a decreased need for ECMO therapy, improved patient outcome, and lower hospital costs.

Uvulopalatopharyngoplasty with tonsillectomy and adenoidectomy as a treatment for obstructive sleep apnea in neurologically impaired children

RATIONALE Children with neurologic impairment often present with airway obstruction that may require intervention. No single method of airway intervention is universally appropriate and effective in this patient population. This study was performed to examine the effectiveness of using adenotonsillectomy and uvulopalatopharyngoplasty (UPPP) in resolving obstructive apnea (OA) in patients with neurologic impairment. METHODS A retrospective chart review of 15 patients with neurologic impairment and OA treated with adenotonsillectomy and UPPP between 1986 and 1998 at Childrens Hospital of Wisconsin (CHW) was performed. All patients in the series had their primary area of obstruction in the posterior oropharynx involving the soft palate, pharyngeal walls and base of tongue. Post-operative improvement following adenotonsillectomy and UPPP was examined. Measures of improvement were based primarily on recorded lowest oxygen saturations, but clinical parameters, flexible upper airway endoscopy and polysomnography were used as well. RESULTS Patient improvement was documented in 87% of patients treated with this modality. For the group, the mean lowest recorded oxygen saturation demonstrated a statistically significant improvement from 65% pre-operatively to 85% post-operatively (P = 0.005). In long-term follow-up of these patients, 77% (10 of 13) of those showing initial improvement have done well and have required no further airway intervention. However, 23% of these patients demonstrated the need for further airway intervention during follow-up. CONCLUSIONS Adenotonsillectomy with UPPP is worthy of consideration in certain neurologically impaired patients with moderate to severe OA, limited primarily to the posterior pharyngeal area. Initial improvement may not be permanent and close long-term follow-up of patients is imperative.

Epidemiology of central line-associated bloodstream infections in the pediatric intensive care unit

OBJECTIVE Describe central line-associated bloodstream infection (CLA-BSI) epidemiology in pediatric intensive care units (PICUs). DESIGN Descriptive study (29 PICUs); cohort study (18 PICUs). SETTING PICUs in a national improvement collaborative. PATIENTS/PARTICIPANTS Patients admitted October 2006 to December 2007 with 1 or more central lines. METHODS CLA-BSIs were prospectively identified using the National Healthcare Safety Network definition and then readjudicated using the revised 2008 definition. Risk factors for CLA-BSI were examined using age-adjusted, time-varying Cox proportional hazards models. RESULTS In the descriptive study, the CLA-BSI incidence was 3.1/1,000 central line-days; readjudication with the revised definition resulted in a 17% decrease. In the cohort study, the readjudicated incidence was 2.0/1,000 central line-days. Ninety-nine percent of patients were CLA-BSI-free through day 7, after which the daily risk of CLA-BSI doubled to 0.27% per day. Compared with patients with respiratory diagnoses (most prevalent category), CLA-BSI risk was higher in patients with gastrointestinal diagnoses (hazard ratio [HR], 2.7 [95% confidence interval {CI}, 1.43-5.16]; P < .002 ) and oncologic diagnoses (HR, 2.6 [CI, 1.06-6.45]; P = .037). Among all patients, including those with more than 1 central line, CLA-BSI risk was lower among patients with a central line inserted in the jugular vein (HR, 0.43 [CI, 0.30-0.95]; [P < .03). CONCLUSIONS The 2008 CLA-BSI definition change decreased the measured incidence. The daily CLA-BSI risk was very low in patients during the first 7 days of catheterization but doubled thereafter. The risk of CLA-BSI was lower in patients with lines inserted in the jugular vein and higher in patients with gastrointestinal and oncologic diagnoses. These patients are target populations for additional study and intervention.

Comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure.

IMPORTANCE Outcomes associated with use of high-frequency oscillatory ventilation (HFOV) in children with acute respiratory failure have not been established. OBJECTIVE To compare the outcomes of HFOV with those of conventional mechanical ventilation (CMV) in children with acute respiratory failure. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective, observational study using deidentified data obtained from all consecutive patients receiving mechanical ventilation aged 1 month to 18 years in the Virtual PICU System database from January 1, 2009, through December 31, 2011. The study population was divided into 2 groups: HFOV and CMV. The HFOV group was further divided into early and late HFOV. Propensity score matching was performed as a 1-to-1 match of HFOV and CMV patients. A similar matching process was performed for early HFOV and CMV patients. EXPOSURE High-frequency oscillatory ventilation. MAIN OUTCOMES AND MEASURES Length of mechanical ventilation, intensive care unit (ICU) length of stay, ICU mortality, and standardized mortality ratio (SMR). RESULTS A total of 9177 patients from 98 hospitals qualified for inclusion. Of these, 902 (9.8%) received HFOV, whereas 8275 (90.2%) received CMV. A total of 1764 patients were matched to compare HFOV and CMV, whereas 942 patients were matched to compare early HFOV and CMV. Length of mechanical ventilation (CMV vs HFOV: 14.6 vs 20.3 days, P < .001; CMV vs early HFOV: 14.6 vs 15.9 days, P < .001), ICU length of stay (19.1 vs 24.9 days, P < .001; 19.3 vs 19.5 days, P = .03), and mortality (8.4% vs 17.3%, P < .001; 8.3% vs 18.1%, P < .001) were significantly higher in HFOV and early HFOV patients compared with CMV patients. The SMR in the HFOV group was 2.00 (95% CI, 1.71-2.35) compared with an SMR in the CMV group of 0.85 (95% CI, 0.68-1.07). The SMR in the early HFOV group was 1.62 (95% CI, 1.31-2.01) compared with an SMR in the CMV group of 0.76 (95% CI, 0.62-1.16). CONCLUSIONS AND RELEVANCE Application of HFOV and early HFOV compared with CMV in children with acute respiratory failure is associated with worse outcomes. The results of our study are similar to recently published studies in adults comparing these 2 modalities of ventilation for acute respiratory distress syndrome.

Variability in standard care for cytomegalovirus prevention and detection in pediatric lung transplantation: survey of eight pediatric lung transplant programs.

Abstract:  Cytomegalovirus (CMV) infection after pediatric lung transplantation is a significant risk factor for morbidity and mortality in the first year after transplantation. Multiple strategies have been reported for CMV prevention among adult lung transplant programs. In contrast, little information has been reported regarding protocols for prevention and detection of CMV from pediatric programs. We conducted a survey to better understand the range of practice patterns for CMV prevention and detection at pediatric lung transplant centers. A self‐administered questionnaire was distributed to 11 pediatric lung transplant centers identified through the International Pediatric Lung Transplant Collaborative in September 2002. A member of the lung transplant team from each institution was asked to provide the methods of CMV prevention and surveillance. Eight of 11 centers surveyed responded to the questionnaire accounting for 45.6% (26 of 57) and 100% (three of three) of the pediatric lung transplants performed in the US and UK in 2001, respectively. All centers used prophylactic therapy against CMV with either ganciclovir or valganciclovir with duration ranging from 3.5 wk to indefinitely. Most centers (six of eight) prescribed a prophylactic regimen based on donor and recipient CMV serostatus. Half (four of eight) of the centers report using CMV hyperimmune globulin in addition to an antiviral agent. Method for CMV detection varied widely, including use of conventional viral culture (n = 1), antigenemia (n = 7), and polymerase chain reaction (n = 2). A wide range of strategies is used to prevent and detect CMV in pediatric lung transplant recipients with little empiric evidence demonstrating the optimal approach. A retrospective analysis among these centers is being conducted to evaluate the efficacy of these approaches.

Epidemiology and outcomes of in-hospital cardiac arrest in critically ill children across hospitals of varied center volume: a multi-center analysis.

OBJECTIVE To describe epidemiology and outcomes associated with cardiac arrest among critically ill children across hospitals of varying center volumes. METHODS Patients <18 years of age in the Virtual PICU Systems (VPS, LLC) Database (2009-2013) were included. Patients with both cardiac and non-cardiac diagnoses were included. Data on demographics, patient diagnosis, cardiac arrest, severity of illness and outcomes were collected. Hierarchical cluster analysis was performed to categorize all the participating centers into low, low-medium, high-medium, and high volume groups using the center volume characteristics (annual hospital discharges per center, annual extracorporeal membrane oxygenation per center, and annual mechanical ventilators per center). Multivariable models were used to evaluate association of center volume with incidence of cardiac arrest, and mortality after cardiac arrest, adjusting for patient and center characteristics. RESULTS Of 329,982 patients (108 centers), 2.2% (n=7390) patients had cardiac arrest with an associated mortality of 35% (n=2586). In multivariable models controlling for patient and center characteristics, center volume was not associated with either the incidence of cardiac arrest (OR: 1.00; 95% CI: 0.95-1.06; p=0.98), or mortality in those with cardiac arrest (OR: 0.93; 95% CI: 0.82-1.06; p=0.27). These associations were similar across cardiac and non-cardiac disease categories. Furthermore, we demonstrated that there was no correlation between incidence of cardiac arrest and mortality in those with cardiac arrest across different study hospitals in adjusted models. CONCLUSIONS Both incidence of cardiac arrest, and mortality in those with cardiac arrest vary substantially across hospitals. However, center volume is not associated with either of these outcomes, after adjusting for patient and center characteristics.

Ischemic hepatitis in children: diagnosis and clinical course

Hepatic hypoperfusion can result in ischemic hepatitis, a clinical syndrome characterized by a sudden rise in serum transaminases followed by resolution to near normal levels within 7 to 10 days. Although described in adults, this syndrome has not been well defined in pediatric patients. We report 22 children who developed ischemic hepatitis during an acute illness. Fifteen of 22 patients had a documented hypotensive episode or no cardiac output before the onset of the ischemic hepatitis episode. Four of the seven patients without documented hypotension required pressor therapy to maintain their BP. SGOT showed a marked rise (mean 2294 IU/L, range 438 to 6652) from admission to 96 h (mean 34) with a rapid decline to near normal levels within 9 days (mean 5.1). Serum bilirubin levels also rose transiently, but generally not to the extent of transaminase levels. A clinically significant coagulopathy occurred in six patients. Although nine patients expired, none died as a direct result of the hepatic damage. Ischemic hepatitis can occur during illnesses associated with diminished hepatic blood flow and follows a characteristic course that usually can be differentiated from viral or drug-induced hepatitis on clinical and biochemical criteria.