A multifaceted quality improvement project improves intraoperative redosing of surgical antimicrobial prophylaxis during pediatric surgery
2019; 29 (7): 705?11
Differential Lung Ventilation Using a Bronchial Blocker in a Pediatric Patient on Extracorporeal Membrane Oxygenation: A Case Report.
Association Between Race and Ethnicity in the Delivery of Regional Anesthesia for Pediatric Patients: A Single-Center Study of 3189 Regional Anesthetics in 25,664 Surgeries.
Anesthesia and analgesia
We describe a patient with acute on chronic respiratory failure after a cardiac arrest who was cannulated to venoarterial extracorporeal membrane oxygenation. The patient developed right-sided interstitial emphysema with air leak and left-sided hemothorax with secondary atelectasis. A differential lung ventilation strategy was used in which an endotracheal tube was placed in the left main stem bronchus and a bronchial blocker was placed in the right mainstem bronchus. The patient's overall pulmonary function improved, and he was successfully decannulated from extracorporeal membrane oxygenation. In conclusion, differential lung ventilation may be performed in patients on extracorporeal membrane oxygenation with disparate lung disease as an alternative ventilation strategy.
View details for DOI 10.1213/XAA.0000000000001025
View details for PubMedID 31162224
A multifaceted quality improvement project improves intraoperative redosing of surgical antimicrobial prophylaxis during pediatric surgery.
Racial and ethnic disparities in health care are well documented in the United States, although evidence of disparities in pediatric anesthesia is limited. We sought to determine whether there is an association between race and ethnicity and the use of intraoperative regional anesthesia at a single academic children's hospital.We performed a retrospective review of all anesthetics at an academic tertiary children's hospital between May 4, 2014, and May 31, 2018. The primary outcome was delivery of regional anesthesia, defined as a neuraxial or peripheral nerve block. The association between patient race and ethnicity (white non-Hispanic or minority) and receipt of regional anesthesia was assessed using multivariable logistic regression. Sensitivity analyses were performed comparing white non-Hispanic to an expansion of the single minority group to individual racial and ethnic groups and on patients undergoing surgeries most likely to receive regional anesthesia (orthopedic and urology patients).Of 33,713 patient cases eligible for inclusion, 25,664 met criteria for analysis. Three-thousand one-hundred eighty-nine patients (12.4%) received regional anesthesia. One thousand eighty-six of 8884 (13.3%) white non-Hispanic patients and 2003 of 16,780 (11.9%) minority patients received regional anesthesia. After multivariable adjustment for confounding, race and ethnicity were not found to be significantly associated with receiving intraoperative regional anesthesia (adjusted odds ratios [ORs] = 0.95; 95% confidence interval [CI], 0.86-1.06; P = .36). Sensitivity analyses did not find significant differences between the white non-Hispanic group and individual races and ethnicities, nor did they find significant differences when analyzing only orthopedic and urology patients, despite observing some meaningful clinical differences.In an analysis of patients undergoing surgical anesthesia at a single academic children's hospital, race and ethnicity were not significantly associated with the adjusted ORs of receiving intraoperative regional anesthesia. This finding contrasts with much of the existing health care disparities literature and warrants further study with additional datasets to understand the mechanisms involved.
View details for DOI 10.1213/ANE.0000000000004456
View details for PubMedID 31569162
Programmed Intermittent Bolus Regimen for Erector Spinae Plane Blocks in Children: A Retrospective Review of a Single-Institution Experience.
Anesthesia and analgesia
Accurate intraoperative antibiotic redosing contributes to prevention of surgical site infections in pediatric patients. Ensuring compliance with evolving national guidelines of weight-based, intraoperative redosing of antibiotics is challenging to pediatric anesthesiologists.Our primary aim was to increase compliance of antibiotic redoses at the appropriate time and appropriate weight-based dose to 70%. Secondary aims included a subset analysis of time compliance and dose compliance individually, and compliance based on order entry method of the first dose (verbal or electronic).At a freestanding, academic pediatric hospital, we reviewed surgical cases between May 1, 2014 and October 31, 2017 requiring antibiotic redoses. After an institutional change in cefazolin dosing in May 2015, phased interventions to improve compliance included electronic countermeasures to display previous and next dose timing, an alert five minutes prior to next dose, and weight-based dose recommendation (September 2015). Physical countermeasures include badge cards, posting of guidelines, and updates to housestaff manual (September 2015). Statistical process control charts were used to assess overall antibiotic redose compliance, time compliance, and dose compliance. The chi-square test was used to analyze group differences.3,015 antibiotic redoses were administered during 2,341 operative cases between May 1, 2014 and October 31, 2017. Mean monthly compliance with redosing was 4.3% (May 2014-April 2015) and 73% (November 2015-October 2017) (p < 0.001). Dose-only compliance increased from 76% to 89% (p < 0.001) and time-only compliance increased from 4.9 to 82% (p < 0.001). After implementation of countermeasures, electronic order entry compared with verbal order was associated with higher dose compliance, 90% vs. 86% (p = 0.015).This quality improvement project, utilizing electronic and physical interventions, was effective in improving overall prophylactic antibiotic redosing compliance in accordance with institutional redosing guidelines. This article is protected by copyright. All rights reserved.
View details for PubMedID 31034725
A Retrospective Review of a Bed-mounted Projection System for Managing Pediatric Preoperative Anxiety.
Pediatric quality & safety
2018; 3 (4): e087
With few published reports on erector spinae plane block use in children, limited guidance on perioperative local anesthetic dosing exists. We present a series of 22 patients who received erector spinae plane catheters with programmed intermittent bolus for various surgeries. Median loading dose of 0.4 mL/kg (interquartile range [IQR], 0.1 mL/kg) ropivacaine 0.5%, intraoperative bolus of 0.3 mL/kg/h (IQR, 0.1 mL/kg) ropivacaine 0.2%, and a postoperative programmed intermittent bolus regimen of maximum 0.6 mg/kg/h resulted in highest pain scores on postoperative day 1 with a median score of 1.7 of 10 (IQR, 1.8) and highest morphine equivalents consumed on postoperative day 2 with a median score of 0.16 mg/kg up to 120 hours after surgery.
View details for DOI 10.1213/ANE.0000000000003817
View details for PubMedID 30252704
Intraoperative antibiotic redosing compliance and the extended postoperative recovery period: often overlooked areas that may reduce surgical site infections.
Introduction: Most children undergoing anesthesia experience significant preoperative anxiety. We developed a bedside entertainment and relaxation theater (BERT) as an alternative to midazolam for appropriate patients undergoing anesthesia. The primary aim of this study was to determine if BERT was as effective as midazolam in producing cooperative patients at anesthesia induction. Secondary aims reviewed patient emotion and timeliness of BERT utilization.Methods: We conducted a retrospective cohort study of pediatric patients undergoing anesthesia at Lucile Packard Children's Hospital Stanford between February 1, 2016, and October 1, 2016. Logistic regression compared induction cooperation between groups. Multinomial logistic regression compared patients' emotion at induction. Ordinary least squares regression compared preoperative time.Results: Of the 686 eligible patients, 163 were in the BERT group and 150 in the midazolam. Ninety-three percentage of study patients (290/313) were cooperative at induction, and the BERT group were less likely to be cooperative (P = 0.04). The BERT group was more likely to be "playful" compared with "sedated" (P < 0.001). There was a reduction of 14.7 minutes in preoperative patient readiness associated with BERT (P = 0.001).Conclusions: Although most patients were cooperative for induction in both groups, the midazolam group was more cooperative. The BERT reduced the preinduction time and was associated with an increase in patients feeling "playful."
View details for PubMedID 30229198
Enhancing pediatric airway safety using the electronic medical record.
It was with great interest that we read Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures by Morse, et al.1 The authors should be applauded for presenting a well-balanced review of the rationale behind the use of prophylactic antibiotics, data supporting dosing intervals, and potential outcome measures. This article is protected by copyright. All rights reserved.
View details for PubMedID 30592343
A Postoperative Care Bundle Reduces Surgical Site Infections in Pediatric Patients Undergoing Cardiac Surgeries.
Joint Commission journal on quality and patient safety
Difficult intubations are not uncommon in tertiary care children's hospitals, and effective documentation of the difficult airway is a fundamental element of safe airway management. The primary goal of our quality improvement initiative was to improve access to airway information via an alert and documentation system within the electronic medical record (EMR).We created a difficult airway alert within the EMR, linking common airway evaluation templates used by specialists involved in airway management. We assessed the time required for different specialists to answer an airway information questionnaire using the electronic charts of patients before and after the EMR modification. Satisfaction with the EMR modification was also surveyed.Questionnaires were administered to 12 participants before the Epic (Epic Systems Corp., Verona, WI) changes were implemented and to 19 participants after they were implemented. Each participant was asked to answer the airway data questionnaire for two patients, for a total of 24 questionnaires before the EMR changes and 38 questionnaires after the changes. Respondents averaged 7.24 minutes to complete the entire airway data questionnaire before the EMR changes and 3.16 minutes following modification (P?0.0001). Correct airway information was more consistently collected with the modified EMR (98.6% vs 51.4%, P?0.00001). Satisfaction surveys revealed that participants found the accessibility of airway data to be significantly improved following the EMR changes.An EMR airway alert that provides rapid access to relevant airway information critical tool during urgent and emergent events. Based on our preliminary data, further use of this instrument is expected to continue to improve patient safety and practitioner satisfaction.4. Laryngoscope, 2018.
View details for PubMedID 30195274
A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis.
2017; 27 (7): 702-710
Pediatric patients undergoing cardiac surgeries are at an increased surgical site infection (SSI) risk, given prolonged cardiopulmonary bypasses and delayed sternal closures. At one institution, the majority of cardiac patients developed SSIs during prolonged recoveries in the cardiovascular intensive care unit (CVICU). Although guidelines have been published to reduce SSIs in the perioperative period, there have been few guidelines to reduce the risk during prolonged hospital recoveries. The aim of this project was to study a postoperative SSI reduction care bundle, with a goal of reducing cardiac SSIs by 50%, from 3.4 to 1.7 per 100 procedures.This project was conducted at a quaternary, pediatric academic center with a 20-bed CVICU. Historical control data were recorded from January 2013 through May 2015 and intervention/sustainment data from June 2015 through March 2017. A multidisciplinary SSI reduction team developed five key drivers that led to implementation of 11 postoperative SSI reduction care elements. Statistical process control charts were used to measure process compliance, and Pearson's chi-square test was used to determine differences in SSI rates.Prior to implementation, there were 27 SSIs in 799 pediatric cardiac surgeries (3.4 SSIs per 100 surgeries). After the intervention, SSIs significantly decreased to 5 in 570 procedures (0.9 SSIs per 100 surgeries; p?=?0.0045).This project describes five key drivers and 11 elements that were dedicated to reducing the risk of SSI during prolonged CVICU recoveries from pediatric cardiac surgery, with demonstrated sustainability.
View details for DOI 10.1016/j.jcjq.2018.05.009
View details for PubMedID 30170753
The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg·kg(-1) . This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing.The primary aim was to deliver cefazolin 30 mg·kg(-1) to at least 90% of indicated patients. The secondary aim was to determine differences between accuracy of cefazolin doses when given as an electronic order compared to a verbal order.Data were collected from January 1, 2012 to May 31, 2016. A quality improvement team of perioperative physicians, nurses, and pharmacists implemented a series of interventions including new electronic medical record order sets, personal provider antibiotic dose badges, and utilization of pharmacists to prepare antibiotics to increase compliance with the recommended dose. Process compliance was measured using a statistical process control chart, and dose compliance was measured through electronic analysis of the electronic medical record. Secondary aim data were displayed as percentage of dose compliance. An unpaired t-test was used to determine differences between groups.Between January 1, 2012 and May 31, 2016, cefazolin was administered to 9086 patients. The mean compliance of cefazolin at 30 mg·kg(-1) from May 2013 to March 2014 was 40%, which prompted initiation of this project. From April 2014 to May 2016, a series of interventions were deployed. The mean compliance from September 2015 to May 2016 was 93% with significantly reduced variation and no special cause variation, indicating that the process was in control at the target primary aim. There were 649 cefazolin administrations given verbally and 1929 given with an electronic order between October 1, 2014 and May 31, 2016. During this time period, the rate of compliance of administering cefazolin at 30 mg·kg(-1) was significantly higher when given after an electronic order than when given verbally, 94% vs 76%.This comprehensive quality improvement project improved practitioner compliance with evidence-based preoperative antimicrobial dosing recommendations to reduce the risk of surgical site infections.
View details for DOI 10.1111/pan.13137
View details for PubMedID 28321988