Handoff communication is a point of vulnerability when valuable patient information can be inaccurate or omitted. In 2005 we implemented a protocol to improve the handoff process for children from the operating room to the intensive care unit after cardiac surgery. We performed a cross-sectional study of the present process to understand how users adapt a communication intervention over time. 29 handoff events were observed. Individuals required for the handoff were present at 97% of events. Content items averaged a 53% reporting rate. Some clinical information not specified in the protocol demonstrated a higher reporting rate, such as echocardiogram results (68%) and vascular access (79%). A mean of 2.3 environmental distractions per minute of communication were noted. Participant-directed adjustments in content reporting suggest that a facilitator in process improvement is user-centered innovation. Future handoff communication interventions should reduce nonessential distractions and incorporate a discussion of the anticipated patient course.
Paraquat is an herbicide that is highly toxic to humans. Pediatric ingestion has become uncommon in the United States because of preventative efforts. We report here an unintentional, fatal paraquat ingestion by an 8-year-old child. Storage in an inappropriate container, confusion between herbicide trade names, nonspecific symptoms, and a delay in follow-up produced challenges in the diagnosis. In the absence of a clear history of ingestion, paraquat poisoning should be suspected in children who develop skin and mucous membrane burns, gastrointestinal symptoms, acute kidney injury, and respiratory failure.
Objective Respiratory illnesses compose the most common diagnoses of patients admitted to pediatric intensive care units. In pediatrics, high‐flow nasal cannula (HFNC) therapy is an intermediate level of respiratory support with variability in practice. We conducted a pre‐post intervention study of patients placed on HFNC therapy before and after the implementation of an HFNC protocol. Methods This was a quality improvement/pre‐post intervention study of pediatric patients who received HFNC therapy in our teaching, tertiary care children's hospital between January 2015 and April 2019. Patients were evaluated before and after the implementation of a protocol that promoted initiation of higher flow and rapid weaning. Our primary outcomes were initial flow and rate of weaning pre‐ and post‐protocol; our secondary outcomes were HFNC failure rate (defined as escalation to noninvasive ventilation or mechanical ventilation) and length of hospital stay. Propensity matching was used to account for differences in age and weight pre‐ and post‐protocol. Results In total, 584 patients were included, 292 pre‐protocol, and 292 post‐protocol. The median age was 20 months, and the indication for HFNC therapy was bronchiolitis in 29% of patients. Post‐protocol patients compared to pre‐protocol patients had significantly a higher initial flow (median 14.5 L/min vs. 10 L/min, p < .001) and a higher weaning rate of flow (median 4.1 L/min/h vs. 2.4 L/min/h, p < .001). Post‐protocol patients also had a lower HFNC failure rate (10% vs. 17%, p = .015) and a shorter length of stay (5.97 days vs. 6.80 days, p = .006). Conclusion Among pediatric patients, the implementation of an HFNC protocol increases initial flow, allows for more rapid weaning, and may decrease the incidence of escalation to noninvasive ventilation or mechanical ventilation.
OBJECTIVES: Diabetic ketoacidosis (DKA) is a leading cause of morbidity and mortality in children with type 1 diabetes. We implemented a standardized DKA management protocol by using a 2-bag intravenous (IV) fluid system. The purpose of the study was to examine if the protocol improved clinical outcomes and process efficiency. METHODS:This was a retrospective study of patients who did and did not undergo the protocol. Patients were included if they were 18 years of age or younger, were diagnosed with DKA, admitted to an intensive care unit or stepdown unit, and received continuous IV insulin. RESULTS: Of 119 encounters evaluated, 46 (38.7%) received treatment with the protocol and 73 (61.3%) did not. The median time to normalization of ketoacidosis was 9 hours (IQR 5-12) and 9 hours (IQR 6.5-13) for protocol and non-protocol groups, respectively (p = 0.14). The median duration of IV insulin therapy was 16.9 hours (IQR 13.7-21.5) vs. 21 hours (IQR 15.3-26) for protocol and non-protocol groups (p = 0.03). The median number of adjustments to insulin drip rate was 0 (IQR 0-1) and 2 (IQR 0-3) for protocol and non-protocol groups (p = 0.0001). There was no difference in the incidence of hypokalemia, hypoglycemia, or cerebral edema. CONCLUSIONS: The protocol did not change time to normalization of ketoacidosis but did decrease the duration of insulin therapy, number of adjustments to insulin drip rate, and number of wasted IV fluid bags without increasing the incidence of adverse events.
There is limited research on patient experience in hospitalized pediatric patients. Our aim was to investigate the association of patient demographics and hospital stay characteristics with experience in a tertiary-care, freestanding children’s hospital. We conducted a retrospective cross-sectional study of patient experience surveys. We designated the highest rating as “top-box” and examined data across 8 domains, including overall assessment (OA). A total of 4602 surveys were analyzed. Top-box percentages were lower for younger patients in 6 domains, including OA (0-<1 year old: 57.6%; 1-<4 years old: 61.3%; 4-<12 years old: 68.4%; ≥12 years old: 70.2%; P < .001), and were lower for patients with private insurance in 5 domains, including OA (private 63.2%, public 68.9%; P < .001). There was no association between other demographics (gender, race/ethnicity, primary language) and OA. Overall assessment was also not associated with length of stay ( P = .071) and number of consulting services ( P = .703). The most important domain predictor of OA was personal issues (odds ratio = 4.79), which assessed concern, sensitivity, and communication from staff. In conclusion, patient experience was associated with age and insurance status but not hospital stay characteristics.
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