Objectives: To evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. Design: Prospective pre/post observational study. Setting: A large single-center noncardiac PICU in North America. Patients: All patients less than 18 years old who underwent primary tracheal intubation from August 1, 2014, to September 30, 2018. Interventions: Implementation of apneic oxygenation for all primary tracheal intubation as quality improvement. Measurements and Main Results: Total of 1,373 tracheal intubations (661 preimplementation and 712 postimplementation) took place during study period. Within 2 months, apneic oxygenation use reached to predefined adherence threshold (> 80% of primary tracheal intubations) after implementation and sustained at greater than 70% level throughout the postimplementation. Between the preimplementation and postimplementation, no significant differences were observed in patient demographics, difficult airway features, or providers. Respiratory and procedural indications were more common during preintervention. Video laryngoscopy devices were used more often during the postimplementation (pre 5% vs post 75%; p < 0.001). Moderate oxygen desaturation less than 80% were observed in fewer tracheal intubations after apneic oxygenation implementation (pre 15.4% vs post 11.8%; p = 0.049); severe oxygen desaturation less than 70% was also observed in fewer tracheal intubations after implementation (pre 10.4% vs post 7.2%; p = 0.032). Hemodynamic tracheal intubation associated events (i.e., cardiac arrests, hypotension, dysrhythmia) were unchanged (pre 3.2% vs post 2.0%; p = 0.155). Multivariable analyses showed apneic oxygenation implementation was significantly associated with a decrease in moderate desaturation less than 80% (adjusted odds ratio, 0.55; 95% CI, 0.34–0.88) and with severe desaturation less than 70% (adjusted odds ratio, 0.54; 95% CI, 0.31–0.96) while adjusting for tracheal intubation indications and device. Conclusions: Implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. Use of apneic oxygenation should be considered when intubating critically ill children.
Emergency department (ED) overcrowding is an organizational concern. This article describes how Toyota LEAN methods were used as a performance improvement framework to address ED overcrowding. This initiative also impacted "bolus of patients" or "batching" concerns, which occur when inpatient units receive an influx of patients from EDs and other areas at the same time. In addition to decreased incidence of overcrowding, the organization realized increased interprofessional collaboration.
Objective To understand how routine bedside clinical neurologic assessments are performed in U.S. PICUs. Design Electronic survey. Setting Academic PICUs throughout the United States. Subjects Faculty representatives from PICUs throughout the United States. Interventions None. Measurements and Main Results We surveyed how routine bedside neurologic assessments are reported to be performed in U.S. PICUs and the attitudes of respondents on the utility of these assessments. The survey contained questions regarding 1) components of neurologic assessments; 2) frequency of neurologic assessments; 3) documentation and communication of changes in neurologic assessment; and 4) optimization of neurologic assessments. Surveys were received from 64 of 67 institutions (96%). Glasgow Coma Scale and pupillary refl were the most commonly reported assessments (80% and 92% of institutions, respectively). For patients with acute brain injury, 95% of institutions performed neurologic assessments hourly although assessment frequency was more variable for patients at low risk of developing brain injury and those at high risk for brain injury, but without overt injury. In 73% of institutions, any change detected on routine neuroassessment was communicated to providers, whereas in 27%, communication depended on the severity or degree of neurologic decline. Seventy percent of respondents thought that their current practice for assessing and monitoring neurologic status was suboptimal. Only 57% felt that the Glasgow Coma Scale was a valuable tool for the serial assessment of neurologic function in the ICU. Ninety-two percent felt that a standardized approach to assessing and documenting preillness neurologic function would be valuable. Conclusions Routine neurologic assessments are reported to be conducted in nearly all academic PICUs in the United States with fellowship training programs although the content, frequency, and triggers for communication vary between institutions. Most physicians felt that the current paradigms for neurologic assessments are suboptimal. These data suggest that optimizing and standardizing routine bedside nursing neurologic assessments may be warranted. (Pediatr Crit Care Med 2018; 19:339–344)
Objectives: Estimate the inter-rater reliability of critical care nurses performing a pediatric modification of the Glasgow Coma Scale in a contemporary PICU. Design: Prospective observation study. Setting: Large academic PICU. Patients/Subjects: All 274 nurses with permanent assignments in the PICU were eligible to participate. A subset of 18 nurses were selected as study registered nurses. All PICU patients were eligible to participate. Interventions: None. Measurements and Main Results: PICU nurses were educated and demonstrated proficiency on a pediatric modification of the Glasgow Coma Scale we created to make it more applicable to a diverse PICU population that included patients who are sedated, mechanically ventilated, and/or have developmental disabilities. Each study registered nurse observed a sample of nurses perform the Glasgow Coma Scale, and they independently scored the Glasgow Coma Scale. Patients were categorized as having developmental disabilities if their preillness Pediatric Cerebral Performance Category score was greater than or equal to 3. Fleiss’ Kappa (κ), intraclass correlation coefficient, and percent agreement assessed inter-rater reliability for each Glasgow Coma Scale component (eye, verbal, motor) and age-specific scale (≥ 2 and < 2-yr-old). The overall percent agreement between study registered nurses and nurses was 89% for the eye, 91% for the verbal, and 79% for the motor responses. Inter-rater reliability ranged from good (intraclass correlation coefficient = 0.75) to excellent (intraclass correlation coefficient = 0.96) for testable patients. Agreement on the motor response was significantly lower for children with developmental disabilities (< 2 yr: 59% vs 95%; p = 0.0012 and ≥ 2 yr: 55% vs 91%; p = 0.0012). Agreement was significantly worse for intermediate range Glasgow Coma Scale motor responses compared with responses at the extremes (e.g., motor responses 2, 3, 4 vs 1, 5, 6; p < 0.05). Conclusions: A pediatric modification of the Glasgow Coma Scale performed by trained PICU nurses has excellent inter-rater reliability, although reliability was reduced in patients with developmental disabilities and for intermediate range Glasgow Coma Scale responses. Further research is needed to determine the effectiveness of this Glasgow Coma Scale modification to detect clinical deterioration.
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