Earlier, better prediction of severe AKI has the potential to improve AKI associated patient outcomes. Compared to isolated, context-free changes in SCr, renal angina risk assessment improved accuracy for prediction of severe AKI in critically ill children and young adults.
OBJECTIVE To describe the washout effect after stopping a prevention checklist for ventilator-associated pneumonia (VAP). METHODS VAP rates were prospectively monitored for special cause variation over 42 months in a paediatric intensive care unit. A VAP prevention bundle was implemented, consisting of head of bed elevation, oral care, suctioning device management, ventilator tubing care, and standard infection control precautions. Key practices of the bundle were implemented with a checklist and subsequently incorporated into the nursing and respiratory care bedside flow sheets to achieve long-term sustainability. Compliance with the VAP bundle was monitored throughout. The timeline for the project was retrospectively categorised into the benchmark phase, the checklist phase (implementation), the checklist washout phase, and the flowsheet phase (cues in the flowsheet). RESULTS During the checklist phase (12 months), VAP bundle compliance rose from <50% to >75% and the VAP rate fell from 4.2 to 0.7 infections per 1000 ventilator days (p<0.059). Unsolicited qualitative feedback from frontline staff described overburdensome documentation requirements, form fatigue, and checklist burnout. During the checklist washout phase (4 months), VAP rates rose to 4.8 infections per 1000 ventilator days (p<0.042). In the flowsheet phase, the VAP rate dropped to 0.8 infections per 1000 ventilator days (p<0.047). CONCLUSIONS Salient cues to drive provider behaviour towards best practice are helpful to sustain process improvement, and cessation of such cues should be approached warily. Initial education, year-long habit formation, and effective early implementation demonstrated no appreciable effect on the VAP rate during the checklist washout period.
Objectives
Reports of the burden of hypertension in hospitalized children are emerging, but the prevalence and significance of this condition within the pediatric intensive care unit (PICU) are not well understood. The aims of this study were to validate a definition of hypertension in the PICU and assess the associations between hypertension and acute kidney injury (AKI), PICU length of stay (LOS), and mortality.
Design and Setting
Single center retrospective study using a database of PICU discharges between July 2011 and February 2013.
Patients
All children discharged from the PICU with LOS > 6 hours, aged 1 month through 17 years. Exclusions were traumatic brain injury, incident renal transplant, or hypotension.
Measurements and Main Results
Potential definitions of hypertension utilizing combinations of standardized cutoff percentiles, durations, initiation or dose escalation of antihypertensives, and/or billing diagnosis codes for hypertension were compared using receiver operator characteristic curves against a manual medical record review. Multivariable logistic and linear regression analyses were conducted using the selected definition of hypertension to assess its independent association with AKI and PICU LOS, respectively. A definition requiring 3 systolic and/or diastolic readings above standardized 99th percentiles plus 5 mmHg over 1 day was selected (area under the curve 0.91, sensitivity 94%, specificity 87%). Among the 1,215 patients in this analysis, the prevalence of hypertension was 25%. Hypertension was independently associated with AKI (OR 2.89, 95% CI 1.64–5.09, P<0.01) and increased PICU LOS (1.50 days, 95% CI 0.94–2.05, P<0.01) in multivariable analyses. Deaths were rare—0 in the normotension group and 3 (1%) in the hypertension group—but were statistically different (P=0.02).
Conclusions
Hypertension is common in the PICU and is associated with worse clinical outcomes. Future studies are needed to confirm these results.
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