Introduction: Prolonged mechanical ventilation (MV) is associated with increased patient morbidity and mortality. Medical University of South Carolina (MUSC) PICU is above Solutions for Patient Safety (SPS) national average for unplanned extubations (UE) (In 2020, 0.870 vs 0.5, respectively). Upon review, the majority of UEs in our PICU (67%) do not require reintubation, suggesting an opportunity for earlier extubation attempts. To address this concern, a protocol to increase SBT with the goal to shorten length of MV was implemented. Methods: MUSC PICU SBT protocol was implemented in January 2021. Using QI methodologies, we compared pre and post SBT protocol data. Our SBT process includes daily screening of all intubated patients. Patients who meet criteria complete an SBT the next day. If passed, patient is prepared for extubation. If not successful, areas for optimizing chance of successful SBT are reviewed. Metrics assessed include percentage who qualified for SBT, percentage who completed an SBT, and percentage who were extubated following successful SBT. Secondary measures include rate of UE and rate of reintubation after SBT guided extubation. Data analysis for UE rate includes comparison of pre-protocol data (4/2020 - 12/2020) to post SBT protocol data (cycle 1 1/21 - 9/21 and cycle 2 10/21 - 6/22). Results: A total of 1193 screenings were performed (Cycle A: 612, Cycle B: 581). Cycle A data includes 220 (36%) SBTs, and 85 (39%) had successful SBT. Of the patients who had successful SBT 47 (55%) were extubated and 2 (4%) required reintubation within 24 hours. Cycle B data includes 176 (30%) SBTs, and 156 (89%) had successful SBT. Of the patients who had successful SBT 101 (65%) were extubated and 5 (11%) required reintubation within 24 hours. After implementation of SBT protocol UE rates were reduced by 31% (0.91 to 0.75). Conclusions: MUSC PICU SBT program was feasible and achieved reduction in UE rates. There are opportunities to improve the rate of SBT trial completion and extubation attempts after a successful SBT. Continuing to monitor data for longer period as interventions become more standard practice will determine true outcome.
Introduction: Multiple competency assessment tools exist for CVC insertion, but there is no standardized approach for use. A direct observation, competency checklist tool (CT) for pediatric CVC placement was developed and validity evidence obtained in simulated encounters but not clinical environments. This study aimed to evaluate how the CT performs in a clinical environment and compare it with a global rating scale (GRS) and an entrustment scale (ES), two competency assessments commonly used. Methods: 12-month (7/21-6/22), prospective, multi-site, observational study. With each CVC inserted, supervisors completed 3 assessments of competency (1. CT: 15 steps with dichotomous (Complete/Not Complete) options; 2. GRS: a dichotomous (Competent/Not Competent) assessment; 3. ES: 5-level supervision rating from ‘observe only’ to ‘able to perform procedure unsupervised’). CT inter-item reliability was evaluated with Cronbach’s alpha. CT, GRS, and ES assessments were compared using partial correlations adjusting for clustering of observations in fellows and fellows in programs. Mixed-effects linear, ordinal, and logistic regressions were used to model the effect of fellow year on scales. Results: 17 sites participated with 339 CVC insertions completed by 116 unique fellows. Overall, the CT had an acceptable internal reliability (alpha=0.66 [95% CI 0.6-0.71]). The CT had minimal correlation with the other assessments (GRS R=0.38, ES R=0.29). GRS and ES (R=0.54) were moderately correlated. For the CT, 2nd year fellows had higher scores than 1st year fellows (0.29 [0.08-0.51] points, p=0.008). 3rd year fellows did not have higher scores than 2nd year fellows (p=0.243). For GRS and ES, trainees had higher competency scores with each year of training (year 1 to 2 [(p< 0.001] and year 2 to 3 [p=0.009]). Conclusions: The checklist tool performed acceptably during real-world competency assessment and correlated with fellow year of training from year 1 to 2 but not year 2 to 3, reflecting its strength in assessing competency for novice trainees. Current assessment tools (ES and GRS) did not correlate well with the CT; different competency assessment tools may serve different purposes based on level of training. Further evaluation of these assessment tools is warranted to determine optimal approach to competency assessment.
6505 Background: A small number of patients (super-utilizers) are responsible for much of the cost in healthcare. In several studies, 5% of patients are responsible for 50% of the cost. Healthcare hot-spotting is the strategic use of data to deliver enhanced resources to selected super-utilizers in an effort to improve the quality of care and to reduce costs. Methods: Patients enrolled in the Oncology Care Model (OCM) who were scheduled to receive cytotoxic, targeted therapy or immunotherapy beginning in the fall of 2017 were screened by nurse practitioners prior to initiating treatment in an effort to identify super-utilizers. Risk factors included high risk disease (stem cell transplant, myelodysplastic syndrome, acute leukemia, stage IV disease), significant co-morbidities (CHF, COPD, renal failure, Insulin Dependent Diabetes , presence of a gastrostomy tube), or an admission to the hospital in the past 6 months. Such patients were provided with enhanced services which included twice weekly outreach by a nurse practitioner between 8am and 10am for a telephonic evaluation of their health status. If the patient was found to have either a new problem that required intervention or a worsening chronic problem, then a same-day appointment was made with the nurse practitioner, oncologist, primary care provider or appropriate specialist. Results: Inpatient admissions decreased from 21.3 per 100 OCM beneficiaries to 18.7 per 100 OCM beneficiaries representing a 12.2% decrease. Inpatient costs were reduced from $979 per beneficiary per month (PBPM) to $885 PBPM representing a decrease of $94 PBPM (9.6% decrease). Conclusions: Targeting oncology super-utilizers based on the nature of their diagnosis, co-morbidities, or history of a recent hospital admission and offering telephonic evaluation reduced hospitalizations and decreased cost resulting in a savings of nearly $600,000 per year for our OCM cohort of 600 beneficiaries. [Table: see text]
Previous research indicates the presence of certain odors is associated with enhanced task performance. The present study investigated use of peppermint odor during typing performance, memorization, and alphabetization. Participants completed the protocol twice--once with peppermint odor present and once without. Analysis indicated significant differences in the gross speed, net speed, and accuracy on the typing task, with odor associated with improved performance. Alphabetization also improved significantly under the odor condition but not typing duration or memorization. These results suggest peppermint odor may promote a general arousal of attention, so participants stay focused on their task and increase performance.
Bag-mask ventilation (BMV) is a lifesaving skill required of neonatal and pediatric practitioners, including all those who hold NRP and PALS certification. As neonatal and pediatric practice evolves and further specializes, trainee exposure and opportunity to perform BMV has changed. There exists no standardized definition or measurement of competency in this procedure. Currently, performance in BMV is most often described by global assessment by an expert provider from which competency to perform BMV is inferred. As assessment …
Herpes simplex virus 1 and 2 infections affect up to 50 million people in the United States, with a natural history of recurrent viral shedding with or without recurrence of symptoms. Although many patients remain asymptomatic or with mild symptoms, a spectrum of rare but significant nervous system complications have been reported. Although urinary retention and constipation associated with genital herpesvirus infections is often attributed to painful genital ulcerations, herpesvirus-associated lumbosacral myeloradiculitis has been reported in adults. Here, we report an 18-year-old man with constipation, urinary retention, perineal paresthesias, and erectile dysfunction in the setting of a genital herpes infection. His workup was notable for a cerebrospinal fluid pleocytosis and MRI with enhancement of the cauda equina and nerve roots, all of which are consistent with sacral myeloradiculitis. The patient was treated with a 3-week course of intravenous acyclovir with complete resolution of symptoms. Pediatric practitioners should be aware of this complication of anogenital herpes simplex virus infection because appropriate diagnosis has implications for treatment delivery and duration.
Introduction: Very high doses of narcotics and benzodiazepines are often needed for sedation and analgesia after extensive abdominal surgery in children, with the potential for excessive sedation, prolonged ventilation and withdrawal. Hypothesis: We hypothesized that neuromuscular blockade used as an adjunct to sedation and analgesia during the first postoperative day would decrease need for treating withdrawal without increasing ventilator days and PICU length of stay (LOS). Methods: Starting in July 2011, we gave a weakening dose of atracurium during the first 24 hours after surgery in addition to usual fentanyl, benzodiazepines, morphine and dexmedetomidine to pediatric single or multiple abdominal organ transplant recipients (Group P, n=12). Cumulative narcotic doses given during the first 48 hrs and need for methadone-lorazepam on transfer out of the PICU were compared with a non-paralyzed cohort (Group NP, n=12) from the previous year. Patients with early surgical complications were excluded from analysis. Results: There were no differences in demographics including age, diagnosis and type of transplant. For Group P vs. Group NP, median fentanyl used (µg/Kg/day) was 46.0 (29.7-69.7) vs 24.6 (24.1-29.6) (P= 0.036, Mann-Whitney). Methadone-lorazepam treatment on transfer out of the PICU was less common in Group P (P= 0.046, Fisher’s exact test) with no increase in ventilator days or PICU-LOS as compared to Group NP. Conclusions: We conclude that the use of brief, early post-operative paralysis reduces narcotic dependence without prolonging mechanical ventilation in pediatric abdominal solid organ transplant recipients.
