Adherence to Endotracheal Tube Depth Guidelines and Incidence of Malposition in Infants and Children.
Female; Humans; pediatrics; Male; Ohio; Random Allocation; Incidence; Chi-Square Distribution; Child; Guideline Adherence/*statistics & numerical data; Infant; intubation; Medical Errors/*statistics & numerical data; NRP; PALS; Radiography/*statistics & numerical data; Trachea/diagnostic imaging; tracheal tube malposition; United States; Odds Ratio; Intensive Care Units; Hospitals; Guideline Adherence; Radiography; Intubation; ROC Curve; Confidence Intervals; Inpatients; Human; Chi Square Test; Descriptive Statistics; P-Value; Data Analysis Software; Practice Guidelines; Retrospective Design; Preschool; Thoracic; Intratracheal/adverse effects/standards/*statistics & numerical data; Intratracheal – Standards – United States; Pediatric – Ohio
BACKGROUND: Adherence to guidelines for endotracheal tube (ETT) insertion depth may not be sufficient to prevent malposition or harm to the patient. To obtain an estimate of ETT malpositioning, we evaluated initial postintubation chest radiographs and hypothesized that many ETTs in multiple intubation settings would be malpositioned despite adherence to Pediatric Advanced Life Support and Neonatal Resuscitation Program guidelines. METHODS: In a random subset (randomization table) of 2,000 initial chest radiographs obtained from January 1, 2009, to May 5, 2012, we recorded height, weight, age, sex, ETT inner diameter, and cm marking at the lip from the electronic health record. Chest radiographs of poor quality and with spinal or skeletal deformities were excluded. We defined adherence to Pediatric Advanced Life Support or Neonatal Resuscitation Program guidelines as the difference between predicted and actual ETT markings at the lip as +/- 0.25, +/- 0.50, or +/- 1.0 cm for ETTs of 2.5-4, 4.5-6.0, or \textgreater6.5 mm inner diameter, respectively. We defined the proper position as the ETT tip being below the thoracic inlet (superior border of the clavicular heads) and \textgreater/=1 cm above the carina. Descriptive statistics reported demographics, guideline adherence, and malposition incidence. The chi-square test was used to assess relationships among intubation setting, malposition, and depth guideline adherence (P \textless .05, significant). RESULTS: We reviewed 507 records, 477 of which met inclusion criteria and had sufficient data for analysis. Fifty-six percent of the subjects were male, with median (interquartile range) age 15.2 (3.4-59.4) months, and 330 ETTs (69%) were malpositioned: 39 above the thoracic inlet, and 291 \textless 1 cm above the carina. Of 79 ETTS (17%) that adhered to depth guidelines, 56 (74%) were malpositioned. Three-hundred seventy-three ETTs (83%) did not meet guidelines. Two-hundred sixty-four (68%) were malpositioned. The intubation setting did not influence malposition or guideline adherence (P = .54). CONCLUSIONS: In infants and children, a high proportion of ETTs were malpositioned on the first postintubation chest radiograph, with little influence of guideline adherence.
Volsko Teresa A; McNinch Neil L; Prough Donald S; Bigham Michael T
Respiratory Care
2018
2018-09
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.4187/respcare.06024" target="_blank" rel="noreferrer noopener">10.4187/respcare.06024</a>
From the street to the ICU: a review of pediatric emergency medical services and critical care transport.
Critical care; emergency medical services (EMS); modern medicine; pediatrics
Emergency medical services and critical care transport teams are relatively new parts of the American healthcare delivery system. Although most healthcare providers regularly interact with these groups and rely upon their almost ubiquitous availability, few know how these services developed or what sort of infrastructure currently exists to maintain them. This article provides a focused overview of the history and present practices of both emergency medical services and critical care transport teams, with a concentrated look at the implementation of these services in the pediatric population. Within this context, we also consider current challenges and future opportunities for both groups and conclude with ways to become involved in the improvement of out-of-hospital pediatric critical care.
Lee Sang Hoon; Schwartz Hamilton P; Bigham Michael T
Translational pediatrics
2018
2018-10
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.21037/tp.2018.09.04" target="_blank" rel="noreferrer noopener">10.21037/tp.2018.09.04</a>
Critical Care Transport: How Perilous the Trip.
*Critical Care; Critical Care; Critical Care Family Needs Inventory; Humans
Bigham Michael T; Brilli Richard J
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
2016
2016-10
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1097/PCC.0000000000000927" target="_blank" rel="noreferrer noopener">10.1097/PCC.0000000000000927</a>
Quality Metrics in Neonatal and Pediatric Critical Care Transport: A National Delphi Project.
*Delphi Technique; Airway Management – Standards; Airway Management/standards; Benchmarking; Clinical Indicators; Critical Care – Standards; Critical Care Family Needs Inventory; Critical Care/*standards; Delphi Technique; Health Care; Hospitals; Humans; Multidisciplinary Care Team – Standards; Ohio; Outcome and Process Assessment (Health Care); Outcomes (Health Care); Patient Care Team/standards; Patient Safety – Standards; Patient Safety/standards; Pediatrics – Standards; Pediatrics/*standards; Quality Indicators; Quality of Health Care – Standards; Quality of Health Care/*standards; Special; Tertiary Care Centers; Time Factors; Transportation of Patients – Standards; Transportation of Patients/*standards
OBJECTIVES: The transport of neonatal and pediatric patients to tertiary care facilities for specialized care demands monitoring the quality of care delivered during transport and its impact on patient outcomes. In 2011, pediatric transport teams in Ohio met to identify quality indicators permitting comparisons among programs. However, no set of national consensus quality metrics exists for benchmarking transport teams. The aim of this project was to achieve national consensus on appropriate neonatal and pediatric transport quality metrics. DESIGN: Modified Delphi technique. SETTING: The first round of consensus determination was via electronic mail survey, followed by rounds of consensus determination in-person at the American Academy of Pediatrics Section on Transport Medicine's 2012 Quality Metrics Summit. SUBJECTS: All attendees of the American Academy of Pediatrics Section on Transport Medicine Quality Metrics Summit, conducted on October 21-23, 2012, in New Orleans, LA, were eligible to participate. MEASUREMENTS AND MAIN RESULTS: Candidate quality metrics were identified through literature review and those metrics currently tracked by participating programs. Participants were asked in a series of rounds to identify "very important" quality metrics for transport. It was determined a priori that consensus on a metric's importance was achieved when at least 70% of respondents were in agreement. This is consistent with other Delphi studies. Eighty-two candidate metrics were considered initially. Ultimately, 12 metrics achieved consensus as "very important" to transport. These include metrics related to airway management, team mobilization time, patient and crew injuries, and adverse patient care events. Definitions were assigned to the 12 metrics to facilitate uniform data tracking among programs. CONCLUSIONS: The authors succeeded in achieving consensus among a diverse group of national transport experts on 12 core neonatal and pediatric transport quality metrics. We propose that transport teams across the country use these metrics to benchmark and guide their quality improvement activities.
Schwartz Hamilton P; Bigham Michael T; Schoettker Pamela J; Meyer Keith; Trautman Michael S; Insoft Robert M
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
2015
2015-10
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1097/PCC.0000000000000477" target="_blank" rel="noreferrer noopener">10.1097/PCC.0000000000000477</a>
Use of procalcitonin for the prediction and treatment of acute bacterial infection in children.
Anti-Bacterial Agents/*administration & dosage; Antibiotics – Administration and Dosage; Bacteremia – Blood; Bacteremia – Diagnosis; Bacteremia/blood/diagnosis; Bacterial Infections – Blood; Bacterial Infections – Diagnosis; Bacterial Infections – Drug Therapy; Bacterial Infections/blood/*diagnosis/drug therapy; Biological Markers – Blood; Biomarkers/blood; Calcitonin – Blood; Calcitonin Gene-Related Peptide; Calcitonin/*blood; Child; Humans; Inflammation – Blood; Inflammation – Diagnosis; Inflammation/blood/diagnosis; Predictive Value of Tests; Preschool; Prognosis; Protein Precursors – Blood; Protein Precursors/*blood; Sensitivity and Specificity
PURPOSE OF REVIEW: Procalcitonin (PCT) is increasingly utilized to determine the presence of infection or to guide antibiotic therapy. This review will highlight the diagnostic and prognostic utility of serum PCT in children. RECENT FINDINGS: Recent studies endorse the use of serum PCT to detect invasive infection, to differentiate sepsis from noninfectious systemic inflammatory response syndrome, and to guide antibiotic therapy. Typical values for maximal sensitivity and specificity are less than 0.5 ng/ml for noninfectious inflammation and greater than 2.0 ng/ml for bacterial sepsis. PCT appears to be a reliable indicator of infection. PCT has performed better than C-reactive protein in some settings, though pediatric comparative data are lacking. PCT may aid in diagnosing infection in challenging patient populations such as those with sickle cell disease, congenital heart defects, neutropenia, and indwelling central venous catheters. Antibiotic therapy tailored to serial PCT measurements may shorten the antibiotic exposure without increasing treatment failure. SUMMARY: PCT is a reliable serum marker for determining the presence or absence of invasive bacterial infection and response to antibiotic therapy. Tailoring antibiotics to PCT levels may reduce the duration of therapy without increasing treatment failure, but more research is needed in children.
Pierce Richard; Bigham Michael T; Giuliano John S Jr
Current opinion in pediatrics
2014
2014-06
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1097/MOP.0000000000000092" target="_blank" rel="noreferrer noopener">10.1097/MOP.0000000000000092</a>
A Gap, and Opportunity, in the ICU Admission, Discharge, and Triage Guidelines.
*Patient Discharge; *Triage; Hospitalization; Humans; Intensive Care Units; Patient Admission; Patient Discharge; Scales; Triage
Frakes Michael A; Wilcox Susan R; Bigham Michael T; Angelotti Timothy; Marcolini Evie G; Cohen Jason
Critical care medicine
2017
2017-03
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1097/CCM.0000000000002202" target="_blank" rel="noreferrer noopener">10.1097/CCM.0000000000002202</a>
Temperature-sensitive Medications in Interfacility Transport: The Ice Pack Myth.
*Air Ambulances; *Pharmaceutical Preparations; *Point-of-Care Systems; *Temperature; Cold – Equipment and Supplies; Drug Storage/standards; Drugs; Emergency Medical Services; Refrigeration – Methods; Refrigeration/*methods/standards; Temperature; Time Factors; Transportation
INTRODUCTION: Critical Care Transport teams use various strategies to maintain temperature sensitive drugs and equipment at optimal temperature. The purpose of this study was to examine the effectiveness of current passive refrigeration of temperature sensitive transport medications/equipment. METHODS: Initially, we performed a retrospective review of transport durations. Subsequently, an experimental paradigm was created using a temperature probe inside of the transport cooler packs utilizing various configurations and initial starting temperatures with high and low "in range" temperature margins of 8 degrees C (max) and 2 degrees C (min). RESULTS: The mean round-trip transport time was 2.5 hours and over 15% of transports last longer than 4 hours. At a starting temperature of -3.9 degrees C, the cooler and ice pack maintained "in range" temperatures for 3 hours. When the ice pack starting temperature was -12.9 degrees C, high temperatures excursions weren't experienced until 6 hours 55 minutes, but initially low excursions fell below for up to 3 hours. iSTAT((R)) cartridges remained within range between 1-4 hours at cooler and ice pack starting temperature of -3.9 degrees C. CONCLUSION: The current system of passive refrigeration does not appear to be sufficient for safely storing medications or point-of-care testing equipment for our transport services. This might reveal a flaw in the existing practices around medication refrigeration in transport.
Clancy Jason; Karish Cassandra; Roddy Meghan; Sicilia Judith J; Bigham Michael T
Air medical journal
2017
2017-12
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1016/j.amj.2017.05.002" target="_blank" rel="noreferrer noopener">10.1016/j.amj.2017.05.002</a>