Yadin David

Resting energy expenditure and nitrogen balance in critically ill pediatric patients on mechanical ventilation.

Nutritional support is important in critically ill patients, with variable energy and nitrogen requirements (e.g., sepsis, trauma, postsurgical state) in this population. This study investigates how age, severity of illness, and mechanical ventilation are related to resting energy expenditure (REE) and nitrogen balance. Nineteen critically ill children (mean age, 8 +/- 6 [SD] y and range 0.4-17.0 y) receiving total parenteral nutrition (TPN) were enrolled. We used indirect calorimetry to measure REE. Expected energy requirements (EER) were obtained from Talbot tables. Pediatric Risk of Mortality (PRISM) and Therapeutic Intervention Scoring System (TISS) score were calculated. Total urinary nitrogen was measured using the Kjeldahl method. PRISM and TISS scores were 9 +/- 5 and 31 +/- 6 points, respectively. REE was 62 +/- 25 kcal.kg-1.d-1, EER was 42 +/- 11 kcal.kg-1. d-1, and caloric intake was 49 +/- 22 kcal.kg-1.d-1. Nitrogen intake was 279 +/- 125 mg.kg-1.d-1, total urinary nitrogen was 324 +/- 133 mg.kg-1.d-1, and nitrogen balance was -120 +/- 153 mg.kg-1.d-1. The protein requirement in this population was approximately 2.8 g.kg-1.d-1. These critically ill children were hypermetabolic, with REE 48% higher (20 kcal.kg-1.d-1) than expected. Nitrogen balance significantly correlated with caloric and protein intake, urinary nitrogen, and age, but not with severity of illness scores or ventilatory parameters.

Nutrition Requirements in Patients with Toxic Epidermal Necrolysis

Patients with toxic epidermal necrolysis, a severe, exfoliative skin disorder, have clinical features similar to those of partial-thickness burn patients. The literature suggests that they also have similar nutritional requirements. We report two patients diagnosed with toxic epidermal necrolysis on mechanical ventilation, in whom resting energy expenditure and respiratory quotient were measured by indirect calorimetry. The patients were treated using standard burn protocols. Nitrogen balance was calculated by measuring total urinary nitrogen in urine samples obtained over 24 hours. These measurements were done while the patients were on mechanical ventilation and receiving total parenteral nutrition. As in burn patients, early in their course the two patients had resting energy expenditure values twice that predicted. After 12 days of hospitalization, nitrogen balance was negative in patient 1 and positive in patient 2. Energy and protein requirements appear to have been related to the amount of body surface affected.

Planning hospital medical technology management

The appropriate deployment of technology contributes to the improvement in the quality of healthcare delivered, the containment of cost, and to increased access to services offered by the healthcare system. Over the past one-hundred years, the dependence of the healthcare system on medical technology for the delivery of its services has continuously grown. In this system, the technology facilitates the delivery of the human touch. Medical technology enables practitioners to collaboratively intervene together with other caregivers to treat patients in a cost-effective and efficient manner. Technology also enables integration and systems management in a way that contributes to improvements in the level of health indicators. Hospital and clinical administrators are faced with the expectation for return on investment that meets accounting guidelines and financial pressures. This article describes the emerging process for managing medical technology in the hospital and the role that clinical engineers are fulfilling.

Computer-controlled electrical stimulation for quantitative mapping of human cortical function

Cortical mapping with electrical stimulation (ES) in neurosurgical patients typically involves the manually controlled delivery of suprathreshold electrical current to a discrete area of the brain. Limited numbers of trials and imprecise current delivery methods increase the variability of the behavioral response and make it difficult to collect quantitative mapping data, which is especially important in research studies of human cortical function. To overcome these limitations, the authors developed a method for computer-controlled delivery of defined electrical current to implanted intracranial electrodes. They demonstrate that stimulation can be time locked to a behavioral task to rapidly and systematically measure the detection threshold for ES in human visual cortex over many trials. Computer-controlled ES is well suited for the systematic and quantitative study of the function of virtually any region of cerebral cortex. It may be especially useful for studying human cortical regions that are not well characterized and for verifying the presence of stimulation-evoked percepts that are difficult to objectively confirm.

Rectal-scalp temperature difference predicts brain death in children

When brain death in children occurs, commonly the scalp feels cold despite a normal core temperature. This phenomenon might reflect absent cerebral blood flow and metabolic activity. The authors, therefore, measured rectal-scalp temperature differences in critically ill comatose children to test the hypothesis that a particular temperature difference may correlate with clinical brain death. In a prospective cohort study set in a pediatric intensive care unit, rectal-scalp, rectal-abdomen, and rectal-mastoid temperatures in critically ill comatose children older than 18 months of age were measured before and during brain death evaluations. Twelve children were enrolled. Clinical criteria for brain death were met by seven patients, and five patients survived. All of the seven children who died had rectal-scalp temperature differences greater than 4 degrees C (mean = 6.7, range = 6.0-7.4) at the time of clinical brain death. No survivor had a rectal-scalp temperature difference of 4 degrees C at any time (mean = 3.4, range = 2.9-3.9). Rectal-scalp temperature differences of those who died and those who survived were significantly different at the P < 0.005 level. Rectal-abdomen and rectal-mastoid temperature differences did not correlate with clinical brain death or rectal-scalp temperature difference. In this preliminary study a rectal-scalp temperature difference of greater than 4 degrees C correlates with clinical criteria for brain death in children.

Risk Assessment &#8211; Hospital View in Selecting Medical Technology

Appropriate deployment of technological innovation contributes to improvement in the quality of healthcare delivered, the containment of cost, and access to the healthcare system. Hospitals have been allocating a significant portion of their resources to procuring and managing capital assets; they are continuously faced with demands for new medical equipment and are asked to manage existing inventory for which they are not well prepared. To objectively direct their investment, hospitals are developing medical technology management programs that need pertinent information and planning methodology for integrating new equipment into existing operations as well as for mitigating patient safety issues and costs of ownership. Clinical engineers identify technological solutions based on the matching of new medical equipment with hospitals objectives. They review their institutions overall technological position, determine strengths and weaknesses, develop equipment-selection criteria, supervise installations, train users and monitor post procurement performance to assure meeting of goals. This program, together with consistent assessment methodology and evaluation analysis, will objectively guide the capital assets decision-making process. At Texas Childrens Hospital we integrated engineering simulation, bench testing and clinical studies with financial information to assure the validity of risk avoidance practice and the promotion of medical equipment and supplies selection based on quantitative measurement process and product comparison practice. The clinical engineers skills and expertise are needed to facilitate the adoption of an objective methodology for implementing the program, thus improving the match between the hospitals needs and budget projections, equipment performance and cost of ownership. The result of systematic planning and execution is a program that assures the safety and appropriateness of inventory level at the lowest life-cycle costs at the best performance.

Attitudes and Practices Related to Clinical Alarms: A Follow-up Survey

&NA; Background Alarm fatigue is a widely acknowledged patient safety concern in hospitals. In 2013, The Joint Commission issued a National Patient Safety Goal on Alarm Management, making addressing alarm management a priority. To capture changes in attitudes and practices related to alarms, the Healthcare Technology Foundation conducted and reported findings from national online surveys in 2006 and 2011 and completed a third survey in 2016. Objectives The goal of the 2016 survey was to identify how hospital practices and clinicians perceptions of alarms have changed since 2006. Methods The online survey was distributed via national health care organizations during a 2‐month period. Results of the 2016 survey (N = 1241) were compared with results of the 2006 and 2011 surveys by using &khgr;2 and Kruskal‐Wallis analyses. Results Responses were significantly different for almost all items across the 3 surveys. Respondents in 2016 were more likely to agree that nuisance alarms occur frequently and disrupt patient care and were less likely to agree that clinical staff responds quickly to alarms. Compared with respondents in 2011, those in 2016 were almost twice as likely to report that their hospitals had experienced adverse events related to alarms in the past 2 years. However, in 2016 a much higher proportion of respondents indicated that their hospitals had implemented alarm improvement initiatives. Conclusions Although survey findings show disappointing trends in the past 10 years, including worsening perceptions of nuisance alarms and more alarm‐related adverse events, the increase in alarm improvement initiatives is encouraging.

Improving Patient Safety Through Clinical Alarms Management

Clinical alarms warn caregivers of immediate or potential adverse patient conditions. Alarms must be accurate, intuitive, and provide alerts which are readily interpreted and acted on by clinicians appropriately alarms and their shortcomings have been the topic of numerous studies and analysis. The (JCAHO) established a National Patient Safety (NPS) goal in 2002 to improve the effectiveness of clinical alarms. Despite the technological and healthcare improvements related to efforts to meet the NPS goal, adverse patient events continue to occur related to alarm system design and performance, care management and the complexity of the patient care environment. In 2004, the American College of Clinical Engineering Healthcare Technology Foundation started an initiative to improve clinical alarms. The HTF task force reviews the literature related to clinical alarm factors and analyzes adverse event databases. Forums, meetings and a survey of 1,327 clinicians, engineers, technical staff and managers provided feedback regarding alarm issues. Of particular value is the response from nursing who represented the majority of the respondents.

Technology related decision-making issues in hospitals

The various organizational levels at which hospital health care equipment is assessed are discussed. Strengths and weakness of the process are examined. Suggestions to improve the decision-making process are given.<<ETX>>

Who represents healthcare engineers

The critical role of the engineer in the healthcare delivery system is discussed. It is noted that health care engineers must adapt to this changing environment while still pursuing the professional goals of autonomy, job satisfaction, professional pride, recognized status, and proper compensation. It is suggested that health care engineers would be better served through an examination of the professionalization process itself, placing greater emphasis on the basic, essential elements of professional development clearly presented in the literature.<<ETX>>