Background

Several studies have shown that critically ill children hospitalized in pediatric intensive care units (PICU) receive higher quality of care, have better outcomes and a lower mortality rate compared to those admitted to adult intensive care units.

Objectives

To explain why “Early Childhood Intensive Care” (TIPI) is an Italian Association of Neonatology (SIN) study group.

Methods

Review of 2014 data from the Italian Pediatric Intensive Care Units Network (TIPNet) and of a recent survey on "Enlarged Neonatal Intensive Care Units (NICU)" sent to all members of the Italian Association of Neonatology (SIN).

Results

From the TIPNet Network data it emerges that in Italy there are only 23 PICUs in which children with a mean age of 45.4 ± 54.5 months are hospitalized, 55% of whom are affected by medical conditions (about 50% by acute respiratory problems).According to the survey on "Enlarged NICUs", it emerges that in 66% of 92 NICUs that replayed to the questionnaires, children older than one month of life are currently hospitalized (78% for respiratory diseases).

Conclusion

The new idea of care is to offer, in general hospitals, enlarged NICUs extended to infants and children based on territorial and/or population macro-areas. Therefore, we believe that the management of the critically ill child is certainly an expertise area of the neonatologist who however must acquire specific skills of pediatric intensive medicine. In this context, SIN's TIPI Study Group wants to promote the knowledge of critically ill infants and the subsequent training of all the involved neonatologists.

Background

Extracorporeal membrane oxygenation (ECMO) is a valuable but limited resource for the management of neonatal PPHN with respiratory failure. We had an increased referral rate from our unit for ECMO.

Objectives

Analysed the data of babies with PPHN who were referred for ECMO over a 5 year period (2009-2014) and put measures in place to reduce the referrals.

Methods

Retrospective analysis of all babies with PPHN who were referred for ECMO between 2009 and 2014. We analysed factors such as timing of respiratory symptoms, initial ventilatory support, ,surfactant administration, nitric oxide, and inotrope usage. As part of PDSA cycle, we put measures in place to educate doctors and nurses to manage aggressively and analysed the results with active surveillance.

Results

17 babies with PPHN were referred for ECMO over a five year period(2009-2014). We identified that an earlier diagnosis with prompt escalation of treatment, as per the PPHN guideline; intubation, ventilation, early nitric oxide and inotropes would have prevented some of these infants from deteriorating. We implemented active education programme to junior doctors and nurses highlighting the importance of aggressive management of PPHN. This reduced the referrals from 3 babies/year to one baby every 18 months to 2 years.

Conclusion

With active education programme to junior doctors and nurses regarding management of PPHN, ECMO referrals have successfully decreased from 3/year(2009-2014) to one baby every 18 months to 2 years. This has led to significant quality improvement in the care of neonates with PPHN and also saved money for the Trust for such expensive, yet effective treatments.

Background

Worldwide a variety of techniques are used to secure endotracheal tubes (ETT) to support the breathing of sick neonates. Despite its obviously intended benefits, there are risks attributed to different techniques. There has been no study comparing methods of ETT fixation and experiences of the various teams using them in England.

Objectives

The aim of this study is to review, in Tertiary Neonatal Units (NICU) in England, the different techniques of ETT fixation, the incidence of specific risks and harm associated and the practice followed in local neonatal networks.

Methods

Using a questionnaire, we conducted a telephone survey among all the NICU in England. We contacted 36 neonatal units in England (34 units responded). The survey consisted of 5 questions.

Results

40% of units used Capatex clamps, 21% units used the Neobar fixation device, 27% used the Neo-fit fixation device, 9% stitched the tube to secure it and 3% used a bespoke fixation technique.

Most units felt the methods they used did not allow accidental extubations. One unit felt there was an increase in the number of accidental extubation which could be attributed to their method of fixation. 2 units felt they had only occasional accidental extubations with the Capatex method. 2 units felt there was an increase in nasal septum injury attributable to the Capatex method.

Conclusion

As this is a telephonic survey, there may be bias present which may lead to inaccuracies. Formal unit data would be more useful. We would recommend a formal comparative study to evaluate and improve practice.

Background

The use of mobiles phones among nurses during work hours is a growing trend and can lead to adverse events that could result in serious consequences.

Objectives

To find out the perspectives of registered nurses in PICU about the use of mobile phones during work hours.

Methods

In November 2018 a electronical survey among registered nurses in PICU of Department of paediatric surgery and intensive care unit of University Medical Centre Ljubljana was conducted (80,5% participation).

Results

The survey found that 48,5% of nurses use their mobile phone during work hours occasionally and 18,2% frequently. 72,7% of nurses think that the use of a mobile phone is undisruptive as long is discrete.

In opinion of 36,4% of nurses the use of mobile phone does not affect their work. Majority (90,9%) of nurses think that they do not miss important clinical information because of the use of a mobile phone. 93,9% mentioned that they have never done some mistake regarding that.

Most of nurses use their mobile phone for work purposes to enhance clinical performance and improve patient safety (93,9%). 69,7% of nurses use their mobile phone for making urgent phone call and 12,1% for sending a text message. Only 9,1% of nurses admitted that they use their mobile phone for social activities and playing games.

Conclusion

The use of mobile phones provides opportunities and capabilities to improve healthcare, however their use can be unsafe as well causing distractions. Each healthcare organization should regulate the use of mobile phones by developing an effective policies.

Background

Early rehabilitation in adult critical care is well established and supported by The National Institute for Health and Care Excellence Guidelines [CG83] (2009). Intensive care associated weakness (ICU-AW) is a well published complication with early rehabilitation benefits such as improving recovery of physical function, reduced disability and decreased length of admission to hospital. Several key indicators have been documented in increasing ICU-AW amongst adults however there is no published literature focussing on patterns within peadiatric intensive care (PICU).

Objectives

To identify key indicators and/or patient groups which may be associated with increased rehabilitation requirements following discharge from PICU.

Methods

Over a 12 month period a pilot project collated data following the discharge from PICU. 8 Patients requiring ongoing physiotherapy to restore function were included and PICU length of stay (LOS) and number of physiotherapy contacts recorded.

Reason for admission, Risk of mortality using the Pediatric Index of Mortality score, number of ventilator days, inotropic requirement on admission, number of sedation agents and use of neuromuscular blockade were selected for consideration.

Results

The 4 patients requiring the most physiotherapy contacts all recieved 3 or more sedation agents, all required inotropes, LOS was greater than 7 days and 3 of which were admitted for severe sepsis. A further 2 patients recieved a neuromuscular blockade and a total 3 of 8 were admitted for asthma.

Conclusion

These findings provide key indicators associated with increased rehabilitation requirements and may support the prevalence of ICU-AW amongst PICU. This will allow earlier identification and aid to direct appropriate physiotherapy resources.

Background

Some studies have shown that there are critical times of admission to PICU that can result in worse patient outcomes.

Objectives

The aim of this study was to explore whether time of admission to the PICU is linked to mortality in Children’s Clinical University Hospital.

Methods

This was a retrospective cohort study. Data were extracted from IntelliVue Clinical Information Portfolio (Phillips) covering the time period from January 1, 2012 to December 31, 2016. Time of admission to PICU, age, gender, duration of stay and mortality data were recorded. We used Pediatric Index of Mortality 2 (PIM2) score for risk-adjustment. In-hour was defined as admission from Monday to Friday from 0800 to 1659. In addition we explored whether mortality is linked to admission in a specific time. Descriptive statistics using t-test, Mann-Whitney and Χ² test were performed. Backward likelihood ratio was used for model determinants.

Results

A total of 3642 children were included, of those 2042 were admitted in-hour. In binary regression time of admission was associated with patient outcome. It was noted that morning (0600–0959) admission had highest adjusted mortality while afternoon admission showed lowest adjusted mortality, hence the afternoon admission mortality was used as baselinerisk. Unadjusted out-of-hour admissions showed increased mortality (OR 1.87; 95% Cl: 1.20–2.92), but was lost after adjusting. Adjusted morning admission resulted in OR 3.72 (95% CI: 2.79–5.13).

Conclusion

We discovered that patients admitted to the PICU who died were more likely to be admitted during morning hours. This information is extremely important for planning staffing, hand-over and patient monitoring overnight.

Background

Umbilical venous catheters (UVCs) are commonly used in NICU. Malpositioned UVCs (those not sited in the thoracic inferior vena cava) are associated with risk of serious and life-threatening complications.

Objectives

To monitor changes in UVC tip position over dwell time using plain film anteroposterior X-ray in extreme preterm neonates.

Methods

A retrospective study of all (75) extreme preterm neonates (23+0 - 27+6 weeks) with UVCs sited who were cared for in a tertiary NICU in Bristol, UK between January 2017 and June 2018. Sixty cases met inclusion criteria. Tip position was assessed on x-ray after any initial adjustment of position and on all subsequent x-rays. Good position was defined as between the 7^th and 9^th thoracic vertebrae.

Results

Fifty-seven per cent (34) of UVCs were in a good position after initial adjustment. Mean UVC dwell time was 5.4 (±2.3) days. Mean migration of all well-positioned UVCs was 2.1 (±1.2) vertebral levels during dwell time (after initial adjustment) and 32% (11) remained in a good position throughout dwell time. Sixty seven per cent (23) became malpositioned, all migrating outwards. Thirty eight per cent (13) moved outwards by 3 or more vertebral levels and 44% (15) to the 11^th thoracic vertebra or lower.

Conclusion

This study shows that most well sited UVCs migrated outwards, many sufficiently to risk complications. UVC position needs regular reassessment to alleviate the risks associated with malposition.

Background

The transition from Critical Care to general wards is an important process requiring accurate and clear handover of information to maintain patient safety and continuity of care. A baseline audit performed on our paediatric intensive care unit (PICU) against national guidelines showed that <50% of discharge summaries satisfied expected standards.

Objectives

Our aim was to provide timely, accurate and complete discharge summaries within a 6 month time frame.

Methods

We held ‘brainstorming’ sessions with key stakeholders (doctors, nurses and parents) to identify issues around discharge. ‘Plan, Do, Study, Act’ (PDSA) methodology was used for every test of change based on this feedback. Prospective weekly data was collected after every test of change from February - June 2018. This information came from PICU consultants, nurses and documentation available on clinical information system and guided the quality improvement project. We maintained regular open channels of communication via email to staff with updates on changes and progress. We strove to identify good progress and allocated a 'Star of the Week' to staff who showed best improvements.

Results

We found that the number of discharge summaries that fell in line with national standards rose to 80%. We then focused on 3 main domains- accuracy, appropriateness and completeness to assess for improvements in change. Run charts were utilised to monitor progress over time and overall there were improvements in the 3 domains as assessed by end-users.

Conclusion

Involvement of stakeholders, celebrating success and maintaining open chains of communication played a large role in driving momentum and determining success of the project.

Background

Intubation outwith the theatre environment is associated with higer risks than in-theatre intubation.¹

Objectives

This project set out to improve paediatric airway documentation in PICU.

Methods

A quality improvement project was performed over 24 months with the multiple interventions performed. A 20 chart snapshot audit was performed after each intervention.

Results

Some areas of documentation have shown marked improvement over the audit cycles. Bedside nurse awareness of airway details showed marked improvement with 90-100% (previously 24-75%) being aware of the grade of laryngoscopy. 100% of nurses knew where to find details about previous intubations and the size and length of the endotracheal tube was documented in 100% of cases. Documentation of the ease of bag mask ventilation (BMV) remains largely unchanged with an initial documentation rate of 50%. This fell with the initial two interventions before improving back to 50% in the most recent re-audit. Another area of improvement was documentation of laryngoscopy grade improving across the audit cycles from 79% to 95%. Documentation of the grade of airway proceduralist and ease of intubation showed marked deterioration with the implementation of the electronic monitoring system (falling from 79-100% to 5-10%, and from 28-50% to 15% respectively.

Conclusion

The interventions performed to date have had mixed results with many areas showing improvement in documentation. Implementation of a new electronic system has provided some challenges and will provide an opportunity for further quality improvement interventions. Bedside nurse awareness of essential airway details have shown marked improvement over the duration of this project.

Background

Anemia of prematurity (AOP) is a common problem in growing very low birth weight (VLBW) preterm infants. AOP may require packed red blood cell (PRBC) transfusion, but potential adverse effects exist.

Objectives

The purpose of this study is to examine the effect of reduction of blood loss due to phlebotomy on the AOP, PRBC transfusion and outcome of VLBW preterm infants.

Methods

To decrease blood loss due to phlebotomy, a blood gas analyzer (ABL80 FLEX analyzer) was used to measure blood gas, electrolytes, hematocrit (Hct), and hemoglobin (Hb) with using 0.2ml blood volume in our neonatal intensive care unit since June 2016. Complete blood count, reticulocyte counts, serum iron and ferritin were examined at 30 day-old. The clinical outcomes including frequency of PRBC transfusion were reviewed. We compared the VLBW infants undergone standard blood sampling in previous study (control group, n=20) with the VLBW infants after we have set up a blood gas analyzer (study group, n=84).

Results

Blood loss due to phlebotomy and PRBC transfusion volume at 30 day-old were significant lower in study group than in control group. Hct, reticulocyte and iron level were significantly higher in study group than in control group. There were no significant differences in the proportion of patent ductus arteriosus, severe intraventricular hemorrhage, retinopathy of prematurity and bronchopulmonary dysplasia between the two groups.

Conclusion

The small amount blood sampling resulted in a less PRBC transfusion, less severity of anemia and a greater bone marrow function at 30 days of age.

Background

Spontaneous intestinal perforation (SIP) is one of the most important complication of PDA treatment in VLBW infants with a relative lack of studies quantifying the risk factors

Objectives

To create a predictive PDA risk model for SIP to assist in weighing the pros and cons of PDA treatment.

Methods

A cohort study of VLBW infants comparing SIP infants with non-SIP controls was conducted, to obtain significant risk factors. The impacts of SIP in terms of mortality, BPD, IVH, ROP and growth parameters were assessed.

Results

389 VLBW infants were included, with 9 having SIP (2.3%). Risk factors for SIP were lower birthweights, more resuscitation at birth, hypotension, PDA medication and culture proven late onset sepsis.
A risk model was created to assess PDA treatment risk. If VLBW babies were not treated with PDA medication, the risk of SIP was completely precluded. However, if PDA medications were started, the presence of any 2 of 3 major risk factors, namely hypotension, extensive birth resuscitation or culture proven LOS would render the risk unacceptably high.
If SIP developed, mortality was 44.4% and associated with BPD requiring postnatal steroids, IVH, severe IVH and cholestasis. Smaller head circumference percentile by gestation at discharge was also found. No association was found with ROP.

Conclusion

SIP is a complication of PDA medical treatment associated with high mortality and morbidities. Risk modeling based on 3 major risk factors can help inform the clinical decision on whether to proceed with treatment for these babies with PDA.