Uma R. Kotagal

Hemodynamically significant PDA: an echocardiographic and clinical assessment of incidence, natural history, and outcome in very low birth weight infants maintained in negative fluid balance.

SummaryFifty very low birth weight (VLBW) infants (750–1500 g, 27–33 weeks gestational age) were assigned at random to one of two groups of negative fluid balance and underwent prospective clinical and echocardiographic examinations during the first month of life. The purpose was to determine: (a) the effect of fluid restriction on the incidence of ductal shunting, (b) the reliability of the physical examination in diagnosing significant ductal shunting, and (c) the relationship between significant ductal shunting and outcome in such infants. None of the infants had manipulations to close the ductus during the first week of life. Using routine structural and functional echocardiographic indices as criteria for the diagnosis of hemodynamically significant ductal shunting (hsPDA), we found that the two fluid-balance groups (8%–10% weight loss vs 13%–15% weight loss) did not significantly differ in incidence of hsPDA, duration of ventilation, or development of BPD. These two groups were then combined for further analysis: 32 (64%) of 50 VLBW infants had hsPDA during the first week of life. The group of infants with hsPDA did not differ significantly from that without hsPDA in birth weight or gestational age, but had a significantly lower Apgar score (P<0.04) and was significantly more likely to require ventilator support for RDS (P<0.01). Although when present a typical ductal murmur was specific for the development of significant ductal shunting, no murmur was heard in 21 (66%) of 32 infants with early hsPDA. Of the infants requiring ventilator support for RDS, the group with early hsPDA needed ventilation for 13.8±9.4 days, significantly longer than the group without early hsPDA (3.2±2.6 days,P<0.001), and had a higher incidence of BPD and death than the group without early hsPDA (P<0.04). In our study of a large group of prospectively identified VLBW infants, we did not find that significant ductal shunting was altered by more stringent fluid restriction, but we did find that such shunting was frequently inapparent clinically, and was associated with significantly increased morbidity and mortality.

Evidence-Based Practice to Reduce Central Line Infections

BACKGROUND In 2003, through the Greater Cincinnati Health Council nine health care systems agreed to participate and fund 50% of a two-year project to reduce hospital-acquired infections among patients in intensive care units (ICU) and following surgery (SIP). METHODS Hospitals were randomized to either the CR-BSI or SIP project in the first year, adding the alternative project in year 2. Project leaders, often the infection control professionals, implemented evidence-based practices to reduce catheter-related blood stream infections (CR-BSIs; maximal sterile barriers, chlorhexidine) at their hospitals using a collaborative approach. Team leaders entered process information in a secure deidentifled Web-based database. RESULTS Of the four initial sites randomized to CR-BSI reduction, all reduced central line infections by 50% (CR-BSI, 1.7 to 0.4/1000 line days, p < .05). At the project midpoint (3 quarters of 2004), adherence to evidence-based practices increased from 30% to nearly 95%. DISCUSSION The direct role of hospital leadership and development of a local community of practice, facilitated cooperation of physicians, problem solving, and success. Use of forcing functions (removal of betadine in kits, creation of an accessory pack and a checklist for line insertion) improved reliability. The appropriate floor for central line infections in ICUs is < 1 infection /1,000 line days.

Effects of quality improvement in health facilities and community mobilization through women's groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial

Background Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi. Methods We evaluated a rural participatory women’s group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14 576 and 20 576 births were recorded during baseline (June 2007–September 2008) and intervention (October 2008–December 2010) periods. Results For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60–1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72–0.97). We did not observe any intervention effects on maternal mortality. Conclusions Despite implementation problems, a combined community and facility approach using participatory women’s groups and quality improvement at health centres reduced newborn mortality in rural Malawi.

Impact of liver transplantation on HRQOL in children less than 5 years old

Abstract:  Our primary goal was to assess health related quality of life (HRQOL) at transplantation and 1 yr after transplantation in pediatric liver transplant patients aged less than 5 years. We conducted a prospective longitudinal study of HRQOL in pediatric liver transplant recipients, aged less than 5 years to define the impact of liver transplantation on HRQOL and identify factors that predict HRQOL after transplantation. The infant toddler health status questionnaire (ITHQ) was completed at the time of listing for liver transplantation and at 6 and 12 months after liver transplantation. The primary outcome measures were the subscale scores that comprise ITHQ. The mean age (±s.e.m.) of the enrolled patients (n = 45) at transplantation was 1.4 (±1.2) yr. Thirty‐eight (84%) of the enrolled patients completed the study. The highest mean baseline scores of 78.6 (±3.3) were for global mental health (GlobalMH). ITHQ subscale scores increased steadily after transplantation. The greatest increase was in the first 6 months after transplant. At 1 yr after transplantation, there were significant increases in all of the ITHQ subscale scores except for GlobalMH. ITHQ subscales were similar for patients who received LDLT compared with those who received cadaver donor liver transplantation (CDLT) at baseline and a year after transplant. Time elapsed as transplantation was a significant predictor of functional health in all of the models generated. Scores for general health (GH), global health (GGH), parental time–impact (PT) and parental time–emotion (PE) were higher for male children. Family cohesion (FC) improved with time elapsed since transplant and increased number of inpatient days. HRQOL improves after transplantation in all of our patients irrespective of the donor type. Functional health scores were higher in patients with normal serum bilirubin at 1 yr post‐transplant. Assessment of HRQOL should be an integral part of care for liver transplant patients and their caregivers.

Healthcare Utilization and Indirect Burden among Families of Pediatric Patients with Chronic Pain

Objectives: Chronic pain is associated with substantial direct and indirect costs in adulthood. Chronic pain problems are also common in childhood, but little is known about the costs of pediatric chronic pain and its treatment. The objectives of this study were to examine and describe healthcare utilization and indirect burden among pediatric chronic pain patients and their families. Methods: Participants were parents of 75 pediatric patients with daily or almost daily pain for at least three months, seen at a multidisciplinary pediatric pain outpatient clinic. Information about healthcare use and indirect familial burden was obtained during a semi-structured interview at the patients* first visit to the pain clinic. A financial analyst extracted cost data regarding hospital charges. To assess change over time, the same information was gathered from parents and the hospital financial analyst six months after their initial visit. Results: Parents reported numerous healthcare visits related to their childs pain condition [e.g., visits to specialists, physical therapy visits], high financial costs [e.g., charges for outpatient visits], and substantial indirect burden [e.g., time spent in medical appointments and missed workdays]. Parents reported lower healthcare utilization and decreased burden on families at the six-month follow-up assessment. Conclusions: Our results suggest that pediatric chronic pain is associated with considerable direct financial costs and indirect familial costs. Preliminary evidence suggests that involvement in a multidisciplinary program may be associated with decreased health care use and indirect burden.

Reducing Surgical Site Infections at a Pediatric Academic Medical Center

BACKGROUND Surgical site infections (SSIs) remain a substantial cause of morbidity, mortality, increased length of stay, and increased hospital costs. Cincinnati Childrens Hospital Medical Center (CCHMC) used reliability science to dramatically reduce the rate of surgical site infections. METHODS Key activities included the development and implementation of strategies to enhance the proportion of patients who receive timely antibiotic administration, a pediatric surgical site infection-prevention bundle, and procedure-specific pediatric surgical site infection-prevention bundles. Measures are presented in monthly reports and annotated control charts that are shared with the improvement team and organizational leadership and that are also posted on the hospitals patient safety intranet site. RESULTS The Class I and II SSI rate decreased from 1.5 per 100 procedure days at baseline to 0.54 per 100 procedure days, a 64% reduction. The process has remained stable (within control limits) since August 2007. There were 33 fewer surgical site infections in fiscal year (FY) 2006 than in FY 2005, and 21 fewer in FY 2007 than in FY 2006. By December 2007, 91% of eligible same-day surgery patients received antibiotics within 60 minutes before a procedure, and 94% of patients undergoing inpatient surgery received antibiotics within 60 minutes prior to incision. DISCUSSION Pediatric surgical patients can now expect a safer, more efficient experience with CCHMCs care system and reduced variation in care across CCHMCs surgeons and procedures. Sharing data on individual and collective provider performance was important in recruiting provider support. Examining data on any failures each day allowed assessment and correction, facilitating rapid-cycle improvement. Making the right thing to do the easy thing to do facilitated the behavior changes required.

Impact of a nurse practitioner-assisted preoperative assessment program on quality

Background : The anesthesia manpower shortage in the last few years in the US has limited many hospital pediatric surgical services. We sought to meet an increasing surgical caseload, while providing safe, timely and patient‐centered care by instituting a nurse practitioner‐assisted preoperative evaluation (NPAPE) program. The strategic goal of this program was to shift anesthesiologists from the preanesthesia clinic to the operating room (OR), while maintaining the quality of preoperative care. Our study sought to evaluate the quality of the NPAPE program.

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis

Objectives To describe how in-depth analysis of adverse events can reveal underlying causes. Methods Triggers for adverse events were developed using the hospitals computerised medical record (naloxone for opiate-related oversedation and administration of a glucose bolus while on insulin for insulin-related hypoglycaemia). Triggers were identified daily. Based on information from the medical record and interviews, a subject expert determined if an adverse drug event had occurred and then conducted a real-time analysis to identify event characteristics. Expert groups, consisting of frontline staff and specialist physicians, examined event characteristics and determined the apparent cause. Results 30 insulin-related hypoglycaemia events and 34 opiate-related oversedation events were identified by the triggers over 16 and 21 months, respectively. In the opinion of the experts, patients receiving continuous-infusion insulin and those receiving dextrose only via parenteral nutrition were at increased risk for insulin-related hypoglycaemia. Lack of standardisation in insulin-dosing decisions and variation regarding when and how much to adjust insulin doses in response to changing glucose levels were identified as common causes of the adverse events. Opiate-related oversedation events often occurred within 48 h of surgery. Variation in pain management in the operating room and post-anaesthesia care unit was identified by the experts as potential causes. Variations in practice, multiple services writing orders, multidrug regimens and variations in interpretation of patient assessments were also noted as potential contributing causes. Conclusions Identification of adverse drug events through an automated trigger system, supplemented by in-depth analysis, can help identify targets for intervention and improvement.

Is the frontal radiograph alone sufficient to evaluate for pneumonia in children

BackgroundIn our cost- and radiation-conscious environment, the feasibility of performing only a frontal radiograph for the diagnosis of pneumonia in children needs to be reassessed.ObjectiveTo determine the diagnostic efficacy of the frontal radiograph alone in comparison to the frontal and lateral combined radiographs for the radiographic diagnosis of pneumonia in children.Materials and methodsThree radiologists retrospectively and independently reviewed the frontal radiographs alone and separately reviewed the frontal and lateral radiographs of 1,268 children referred from the emergency room for chest radiographs. A majority interpretation of at least two radiologists for the frontal views alone was compared with majority interpretation of the frontal and lateral combined views for the radiographic diagnosis of pneumonia. “Pneumonia” was defined as a focus of streaky or confluent lung opacity.ResultsFor the radiographic diagnosis of pneumonia, the sensitivity and specificity of the frontal view alone were 85% and 98%, respectively. For the confluent lobar type of pneumonia, the sensitivity and specificity increased to 100%.ConclusionWhen the frontal view alone yields a diagnosis of confluent lobar pneumonia, this is highly reliable. However, nonlobar types of infiltrates will be underdiagnosed in 15% of patients using the frontal view alone. The clinical impact of these radiographically underdiagnosed pneumonias needs to be assessed prior to implementing the practice of using only frontal radiographs for diagnosing pneumonia.

Health values in adolescents with or without inflammatory bowel disease.

OBJECTIVE To examine for differences in and predictors of health value/utility scores in adolescents with or without inflammatory bowel disease (IBD). STUDY DESIGN Adolescents with IBD and healthy control subjects were interviewed in an academic health center. We collected sociodemographic data and measured health status, personal, family, and social characteristics, and spiritual well-being. We assessed time tradeoff (TTO) and standard gamble (SG) utility scores for current health. We performed bivariate and multivariable analyses with utility scores used as outcomes. RESULTS Sixty-seven patients with IBD and 88 healthy control subjects 11 to 19 years of age participated. Among subjects with IBD, mean (SD) TTO scores were 0.92 (0.17), and mean (SD) SG scores were 0.97 (0.07). Among healthy control subjects, mean (SD) TTO scores were 0.99 (0.03) and mean (SD) SG scores were 0.98 (0.03). TTO scores were significantly lower (P= .001), and SG scores trended lower (P= .065) in patients with IBD when compared with healthy control subjects. In multivariable analyses controlling for IBD status, poorer emotional functioning and spiritual well-being were associated with lower TTO (R(2)=0.17) and lower SG (R(2)=0.22) scores. CONCLUSION Direct utility assessment in adolescents with or without IBD is feasible and may be used to assess outcomes. Adolescents with IBD value their health state highly, although less so than healthy control subjects. Emotional functioning and spiritual well-being appear to influence utility scores most strongly.