Background: Delirium is defined as an acute, global brain dysfunction that is common, yet underap... more Background: Delirium is defined as an acute, global brain dysfunction that is common, yet underappreciated in critically-ill pediatric patients. Delirious patients have longer hospital stays, increased risk of mortality, and higher rates of post-traumatic stress syndrome. To address this problem, several screening tools have been developed to facilitate diagnosis of pediatric ICU delirium. Implementation of delirium screening has been associated with decreased prevalence and improved outcomes. In the initial phase of a broader QI project, we conducted a pre-intervention survey of clinicians and nurses to identify barriers to successful implementation …
Background: The Texas Children’s Hospital (TCH) Pediatric Intensive Care Unit (PICU) is a 35-bed ... more Background: The Texas Children’s Hospital (TCH) Pediatric Intensive Care Unit (PICU) is a 35-bed unit that provides care to around 2,400 critically ill children per year. Approximately 40% are mechanically ventilated. In December 2016, the FDA released an advisory communication emphasizing minimizing exposure to certain classes of commonly used sedation medications. Recent adult guidelines from the Society for Critical Care Medicine have emphasized the use of validated sedation scales, nurse-driven protocols, and ICU-delirium prevention for all mechanically ventilated patients - collectively known as the “ABCDEF Bundle”. Current approaches to sedation in critically ill children tend to be driven …
www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives... more www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Critically ill children are at high risk for developing nutritional deficiencies and undernutrition is known to be a risk factor for morbidity and mortality. The aim of the study was to assess nutritional status and its association with clinical outcome Methods: Retrospective cohort study of children admitted to PICU (1/16-6/16); nutritional status assessed by weight for age (WFA: underweight), height for age (HFA: stunting), and weight for height (WFH: wasting), z-scores by WHO and CDC. Malnutrition defined as mild, and moderatesevere if z-scores were > -1, > -2, respectively. Hospital and PICU length of stay (LOS), and risk of mortality (ROM) by the Pediatric Index of Mortality 2 (PIM2) were obtained. Results: A total of 1057 children (582 males), age 5.4 yrs (1.2–13; median (25-75th IQR)), were included. The hospital LOS was 8 days (4–17); PICU LOS: 2 (1–5) days; PIM2 ROM(%) 1...
OBJECTIVE. We sought to inform decision-making for children and families by describing what is kn... more OBJECTIVE. We sought to inform decision-making for children and families by describing what is known and remains unknown about the impact of childhood critical illness and injury on families. This report also was designed as a tool for research planning and design so that meaningful studies are performed and duplication is avoided. DESIGN. After a national scholarship competition and the identification of 3 medical student summer scholars, a literature search was conducted by using the National Library of Medicine and a PubMed keyword search system at the National Institutes of Health. RESULTS. A total of 115 reports were reviewed and assigned to the 5 following categories characterizing the impact of pediatric critical illness/injury on families: stressors, needs, specific domains (psychological, physical, social), coping, and interventions. The reports reviewed indicate that pediatric critical illness and injury is stressful for the entire family. The effects on parents, siblings,...
Background: The Texas Children’s Hospital (TCH) Pediatric Intensive Care Unit (PICU) is a 35-bed ... more Background: The Texas Children’s Hospital (TCH) Pediatric Intensive Care Unit (PICU) is a 35-bed unit that provides care to around 2,400 critically ill children per year. Approximately 40% are mechanically ventilated. In December 2016, the FDA released an advisory communication emphasizing minimizing exposure to certain classes of commonly used sedation medications. Recent adult guidelines from the Society for Critical Care Medicine have emphasized the use of validated sedation scales, nurse-driven protocols, and ICU-delirium prevention for all mechanically ventilated patients - collectively known as the “ABCDEF Bundle”. Current approaches to sedation in critically ill children tend to be driven …
The Joint Commission Journal on Quality and Patient Safety, 2022
Rapid response (RR) systems' impact on clinical outcomes is influenced by institutional socia... more Rapid response (RR) systems' impact on clinical outcomes is influenced by institutional social factors. This study applied the realist evaluation (context-mechanism-outcomes) framework to review significant RRs defined as REACT (Rapid Escalation After Critical Transfer) events for appraising a pediatric RR system. REACT events included all RRs with cardiopulmonary arrest (CPA) and/or ventilation and/or hemodynamic support instituted within 24 hours after RR. A continuous quality improvement process was employed to identify, debrief, and review REACT events to recognize and act on RR mechanistic and contextual deficiencies. The aim was to decrease REACT events with mechanistic/contextual gaps categorized into crisis resource management (CRM) themes by 25% over three years while ensuring process sustainability. From 2015 to 2019, 5,581 RR events occurred, of which 67.2% transferred to ICU, and 1,392 (24.9%) were identified as REACTs. In the first two years, 100% identification and review within three months of 90% REACTs was accomplished. One hundred percent of the 17 providers ascertained that the process was safe and transparent, and 80.0% of respondents expressed their commitment from perceived benefit to patient care. Over five years, the proportion of REACTs with CRM gaps decreased from 62.3% to 26.5%, those with multiple deficiencies reduced from 72.5% to 23.2%, and CPAs outside ICUs decreased from 15 to 3 per year. Improvement actions included modifications to RR system (activation, process, and management), hospital (resources and policies), dedicated RR training, and sharing of positive feedback. The realist evaluation framework facilitated holistic assessment of an RR system. Review of REACTs was feasible, sustainable, and yielded useful information to guide systemwide improvement.
Background: Delirium is defined as an acute, global brain dysfunction that is common, yet underap... more Background: Delirium is defined as an acute, global brain dysfunction that is common, yet underappreciated in critically-ill pediatric patients. Delirious patients have longer hospital stays, increased risk of mortality, and higher rates of post-traumatic stress syndrome. To address this problem, several screening tools have been developed to facilitate diagnosis of pediatric ICU delirium. Implementation of delirium screening has been associated with decreased prevalence and improved outcomes. In the initial phase of a broader QI project, we conducted a pre-intervention survey of clinicians and nurses to identify barriers to successful implementation …
Background: Delirium is defined as an acute, global brain dysfunction that is common, yet underap... more Background: Delirium is defined as an acute, global brain dysfunction that is common, yet underappreciated in critically-ill pediatric patients. Delirious patients have longer hospital stays, increased risk of mortality, and higher rates of post-traumatic stress syndrome. To address this problem, several screening tools have been developed to facilitate diagnosis of pediatric ICU delirium. Implementation of delirium screening has been associated with decreased prevalence and improved outcomes. In the initial phase of a broader QI project, we conducted a pre-intervention survey of clinicians and nurses to identify barriers to successful implementation …
Background: The Texas Children’s Hospital (TCH) Pediatric Intensive Care Unit (PICU) is a 35-bed ... more Background: The Texas Children’s Hospital (TCH) Pediatric Intensive Care Unit (PICU) is a 35-bed unit that provides care to around 2,400 critically ill children per year. Approximately 40% are mechanically ventilated. In December 2016, the FDA released an advisory communication emphasizing minimizing exposure to certain classes of commonly used sedation medications. Recent adult guidelines from the Society for Critical Care Medicine have emphasized the use of validated sedation scales, nurse-driven protocols, and ICU-delirium prevention for all mechanically ventilated patients - collectively known as the “ABCDEF Bundle”. Current approaches to sedation in critically ill children tend to be driven …
www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives... more www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Critically ill children are at high risk for developing nutritional deficiencies and undernutrition is known to be a risk factor for morbidity and mortality. The aim of the study was to assess nutritional status and its association with clinical outcome Methods: Retrospective cohort study of children admitted to PICU (1/16-6/16); nutritional status assessed by weight for age (WFA: underweight), height for age (HFA: stunting), and weight for height (WFH: wasting), z-scores by WHO and CDC. Malnutrition defined as mild, and moderatesevere if z-scores were > -1, > -2, respectively. Hospital and PICU length of stay (LOS), and risk of mortality (ROM) by the Pediatric Index of Mortality 2 (PIM2) were obtained. Results: A total of 1057 children (582 males), age 5.4 yrs (1.2–13; median (25-75th IQR)), were included. The hospital LOS was 8 days (4–17); PICU LOS: 2 (1–5) days; PIM2 ROM(%) 1...
OBJECTIVE. We sought to inform decision-making for children and families by describing what is kn... more OBJECTIVE. We sought to inform decision-making for children and families by describing what is known and remains unknown about the impact of childhood critical illness and injury on families. This report also was designed as a tool for research planning and design so that meaningful studies are performed and duplication is avoided. DESIGN. After a national scholarship competition and the identification of 3 medical student summer scholars, a literature search was conducted by using the National Library of Medicine and a PubMed keyword search system at the National Institutes of Health. RESULTS. A total of 115 reports were reviewed and assigned to the 5 following categories characterizing the impact of pediatric critical illness/injury on families: stressors, needs, specific domains (psychological, physical, social), coping, and interventions. The reports reviewed indicate that pediatric critical illness and injury is stressful for the entire family. The effects on parents, siblings,...
Background: The Texas Children’s Hospital (TCH) Pediatric Intensive Care Unit (PICU) is a 35-bed ... more Background: The Texas Children’s Hospital (TCH) Pediatric Intensive Care Unit (PICU) is a 35-bed unit that provides care to around 2,400 critically ill children per year. Approximately 40% are mechanically ventilated. In December 2016, the FDA released an advisory communication emphasizing minimizing exposure to certain classes of commonly used sedation medications. Recent adult guidelines from the Society for Critical Care Medicine have emphasized the use of validated sedation scales, nurse-driven protocols, and ICU-delirium prevention for all mechanically ventilated patients - collectively known as the “ABCDEF Bundle”. Current approaches to sedation in critically ill children tend to be driven …
The Joint Commission Journal on Quality and Patient Safety, 2022
Rapid response (RR) systems' impact on clinical outcomes is influenced by institutional socia... more Rapid response (RR) systems' impact on clinical outcomes is influenced by institutional social factors. This study applied the realist evaluation (context-mechanism-outcomes) framework to review significant RRs defined as REACT (Rapid Escalation After Critical Transfer) events for appraising a pediatric RR system. REACT events included all RRs with cardiopulmonary arrest (CPA) and/or ventilation and/or hemodynamic support instituted within 24 hours after RR. A continuous quality improvement process was employed to identify, debrief, and review REACT events to recognize and act on RR mechanistic and contextual deficiencies. The aim was to decrease REACT events with mechanistic/contextual gaps categorized into crisis resource management (CRM) themes by 25% over three years while ensuring process sustainability. From 2015 to 2019, 5,581 RR events occurred, of which 67.2% transferred to ICU, and 1,392 (24.9%) were identified as REACTs. In the first two years, 100% identification and review within three months of 90% REACTs was accomplished. One hundred percent of the 17 providers ascertained that the process was safe and transparent, and 80.0% of respondents expressed their commitment from perceived benefit to patient care. Over five years, the proportion of REACTs with CRM gaps decreased from 62.3% to 26.5%, those with multiple deficiencies reduced from 72.5% to 23.2%, and CPAs outside ICUs decreased from 15 to 3 per year. Improvement actions included modifications to RR system (activation, process, and management), hospital (resources and policies), dedicated RR training, and sharing of positive feedback. The realist evaluation framework facilitated holistic assessment of an RR system. Review of REACTs was feasible, sustainable, and yielded useful information to guide systemwide improvement.
Background: Delirium is defined as an acute, global brain dysfunction that is common, yet underap... more Background: Delirium is defined as an acute, global brain dysfunction that is common, yet underappreciated in critically-ill pediatric patients. Delirious patients have longer hospital stays, increased risk of mortality, and higher rates of post-traumatic stress syndrome. To address this problem, several screening tools have been developed to facilitate diagnosis of pediatric ICU delirium. Implementation of delirium screening has been associated with decreased prevalence and improved outcomes. In the initial phase of a broader QI project, we conducted a pre-intervention survey of clinicians and nurses to identify barriers to successful implementation …
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