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1.
Pediatr Qual Saf ; 6(4): e443, 2021.
Article in English | MEDLINE | ID: mdl-34345756

ABSTRACT

INTRODUCTION: Primary headache is a common cause of pediatric emergency department (PED) visits. Without published guidelines to direct treatment options, various strategies lacking evidence are often employed. This study aims to standardize primary headache treatment in the PED by promoting evidence-based therapies, reducing nonstandard abortive therapies, and introducing dihydroergotamine (DHE) into practice. METHODS: A multidisciplinary team developed key drivers, created a clinical care algorithm, and updated electronic medical record order sets. Outcome measures included the percentage of patients receiving evidence-based therapies, nonstandard abortive therapies, DHE given after failed first-line therapies, and overall PED length of stay. Process measures included the percent of eligible patients with the order set usage and medications received within 90 minutes. Balancing measures included hospital admissions and returns to the PED within 72 hours. Annotated control charts depicted results over time. RESULTS: We collected data from July 2017 to December 2019. The percent of patients receiving evidence-based therapies increased from 69% to 73%. The percent of patients receiving nonstandard abortive therapies decreased from 2.5% to 0.6%. The percent of patients receiving DHE after failed first-line therapies increased from 0% to 37.2%. No untoward effects on process or balancing measures occurred, with sustained improvement for 14 months. CONCLUSION: Standardization efforts for patients with primary headaches led to improved use of evidence-based therapies and reduced nonstandard abortive therapies. This methodology also led to improved DHE use for migraine headache resistant to first-line therapies. We accomplished these results without increasing length of stay, admission, or return visits.

2.
J Neurosurg Pediatr ; 20(6): 567-574, 2017 Dec.
Article in English | MEDLINE | ID: mdl-28984538

ABSTRACT

OBJECTIVE Methylprednisolone sodium succinate (MPSS) has been studied as a pharmacological adjunct that may be given to patients with acute spinal cord injury (ASCI) to improve neurological recovery. MPSS treatment became the standard of care in adults despite a lack of evidence supporting clinical benefit. More recently, new guidelines from neurological surgeon groups recommended no longer using MPSS for ASCI, due to questionable clinical benefit and known complications. However, little information exists in the pediatric population regarding MPSS use in the setting of ASCI. The aim of this paper was to describe steroid use and side effects in patients with ASCI at the authors' Level 1 pediatric trauma center in order to inform other hospitals that may still use this therapy. METHODS A retrospective chart review was conducted to determine adherence in ordering and delivery according to the guideline of the authors' institution and to determine types and frequency of complications. Inclusion criteria included age < 17 years, blunt trauma, physician concern for ASCI, and admission for ≥ 24 hours or treatment with high-dose intravenous MPSS. Exclusion criteria included penetrating trauma, no documentation of ASCI, and incomplete medical records. Charts were reviewed for a predetermined list of complications. RESULTS A total of 602 patient charts were reviewed; 354 patients were included in the study. MPSS was administered in 59 cases. In 34 (57.5%) the order was placed correctly. In 13 (38.2%) of these 34 cases, MPSS was administered according to the recommended timeline protocol. Overall, only 13 (22%) of 59 patients received the therapy according to protocol with regard to accurate ordering and administration. Among the patients with ASCI, 20 (55.6%) of the 36 who received steroids had complications, which was a significantly higher rate than in those who did not receive steroids (8 [24.2%] of 33, p = 0.008). Among the patients without ASCI, 10 (43.5%) of the 23 who received steroids also experienced significantly more complications than patients who did not receive steroids (50 [19.1%] of 262, p = 0.006). CONCLUSIONS High-dose MPSS for ASCI was not delivered to pediatric patients according to protocol with a high degree of reliability. Patients receiving steroids for pediatric ASCI were significantly more likely to experience complications than patients not receiving steroids. The findings presented, including complications of steroid use, support removal of high-dose MPSS as a treatment option for pediatric ASCI.


Subject(s)
Methylprednisolone Hemisuccinate/administration & dosage , Methylprednisolone Hemisuccinate/adverse effects , Neuroprotective Agents/administration & dosage , Neuroprotective Agents/adverse effects , Spinal Cord Injuries/drug therapy , Acute Disease , Adolescent , Child , Child, Preschool , Cohort Studies , Cross-Sectional Studies , Dose-Response Relationship, Drug , Female , Humans , Hyperglycemia/chemically induced , Infant , Infant, Newborn , Male , Nausea/chemically induced , Retrospective Studies , Spinal Cord Injuries/diagnosis
3.
Am J Health Syst Pharm ; 74(17): 1353-1362, 2017 Sep 01.
Article in English | MEDLINE | ID: mdl-28701350

ABSTRACT

PURPOSE: Results of a study to determine whether checklist-based interventions improved the selection and administration of rapid-sequence intubation (RSI) medications in a pediatric emergency department (ED) are reported. METHODS: A retrospective study of data collected during a quality-improvement project was conducted. Data sources included the electronic health record and video review. The central intervention was use of a 21-item RSI checklist, which included guidance for the physician team leader on medication selection and timing. A quick-reference card was developed to guide staff in preparing RSI medications. The main outcomes were (1) standard selection, defined as administration of indicated medications and avoidance of medications not indicated, and (2) efficient administration, defined as an interval of <30 seconds from sedative to neuromuscular blocker (NMB) infusion. RESULTS: A total of 253 consecutive patients underwent RSI during 3 consecutive periods: the historical (preimprovement) period (n = 136), the checklist only period (n = 68), and the checklist/card period (n = 49). The rate of standard selection of 3 RSI medications (atropine, lidocaine, and rocuronium) did not improve. The rate of efficient sedative and NMB administration improved from 56% in the historical period to 88% in the checklist period (p = 0.005). The median duration of RSI medication administration decreased from 28 seconds (interquartile range [IQR], 23-44 seconds) in the historical period to 19 seconds (IQR, 15-25 seconds) in the checklist/card period (p = 0.004). CONCLUSION: In a quality-improvement project in a pediatric ED, a checklist-based intervention improved RSI medication administration technique but not selection.


Subject(s)
Early Medical Intervention/standards , Emergency Service, Hospital/standards , Intubation, Intratracheal/standards , Quality Improvement/standards , Anesthetics, Local/administration & dosage , Child , Child, Preschool , Early Medical Intervention/methods , Female , Humans , Hypnotics and Sedatives/administration & dosage , Infant , Intubation, Intratracheal/methods , Male , Neuromuscular Blocking Agents/administration & dosage , Prospective Studies , Retrospective Studies , Time Factors , Treatment Outcome
4.
Pediatr Emerg Care ; 33(2): 116-119, 2017 Feb.
Article in English | MEDLINE | ID: mdl-28146440

ABSTRACT

PURPOSE: Primary cardiac events are rare in children. There is little information in the literature regarding the most appropriate emergency department (ED) management of this type of pediatric patient, especially with regard to medication use. SUMMARY: This case highlights the pediatric ED evaluation and treatment of sudden collapse in a child with an ultimate diagnosis of hypertrophic cardiomyopathy. Cardiac disorders represent 2% to 6% of cases of pediatric syncope presenting to EDs, particularly if there are previous prodromal symptoms and/or a history of exertion. Evaluation should include electrocardiogram, chest radiograph, and echocardiogram if available. Management should focus on decreasing the potential for a recurring arrhythmia while maintaining cardiac preload, which can be worsened with certain medication use. CONCLUSIONS: Although primary cardiac events in children are rare, a high index of suspicion should be maintained especially with a history of prodromal symptoms or collapse during exertion. If cardiac etiology is suspected, deliberate management should be used to exclude a treatment that could be detrimental. This case report provides an initial assessment and recommendations for management of these patients.


Subject(s)
Cardiomyopathy, Hypertrophic, Familial/complications , Cardiomyopathy, Hypertrophic, Familial/diagnosis , Syncope/etiology , Cardiomyopathy, Hypertrophic, Familial/genetics , Carrier Proteins/genetics , Child , Echocardiography , Electrocardiography , Emergency Medical Services , Emergency Service, Hospital , Heart Ventricles/diagnostic imaging , Humans , Magnetic Resonance Imaging, Cine , Male , Mutation , Sarcomeres/genetics , Stroke Volume
5.
Pediatr Emerg Care ; 31(6): 403-8, 2015 Jun.
Article in English | MEDLINE | ID: mdl-25996232

ABSTRACT

OBJECTIVES: The aims of the study were to analyze and classify reasons why retail pharmacies need to contact the pediatric emergency department (PED) for clarification on outpatient prescriptions generated using an electronic prescribing system and to categorize the severity of errors captured. METHODS: A retrospective chart review was conducted at a PED that cares for approximately 92,000 patients annually. All pharmacy callbacks documented in the electronic medical record between August 1, 2008 and July 31, 2009 were included. A datasheet was used to capture patient demographics (age, sex, race, insurance), prescriptions written, and reason for callback. Each call was then assigned a severity level, and time to respond to all calls was estimated. Frequencies were used to analyze the data. RESULTS: A total of 731 errors for 695 callbacks were analyzed from 49,583 prescriptions written at discharge. The most common errors included administrative/insurance issues 342/731 (47%) and prescription writing errors 298/731 (41%). The errors were classified as insignificant (340/729 [47%]), problematic (288/729 [40%]), significant (77/729 [11%]), serious (12/729 [1.64%]), and severe (12/729 [1.64%]). Almost 96% of errant prescriptions were not able to be filled as originally written and required a change by the prescriber. These calls required approximately 127 hours to complete. CONCLUSIONS: Prescription errors requiring a pharmacy callback are typically insignificant. However, 13.8% of callbacks about an error were considered significant, serious, or severe. Automated dose checking and verifying insurance coverage of prescribed medications should be considered essential components of prescription writing in a PED.


Subject(s)
Drug Prescriptions/statistics & numerical data , Electronic Prescribing/statistics & numerical data , Emergency Service, Hospital/statistics & numerical data , Hospitals, Pediatric/statistics & numerical data , Medication Errors , Patient Discharge , Pharmacy Service, Hospital/statistics & numerical data , Telephone , Trauma Centers/statistics & numerical data , Adolescent , Child , Child, Preschool , Electronic Health Records , Hospitals, Teaching/statistics & numerical data , Hospitals, Urban/statistics & numerical data , Humans , Inappropriate Prescribing , Infant , Insurance Coverage , Insurance, Pharmaceutical Services , Ohio , Practice Patterns, Physicians' , Prescription Fees , Retrospective Studies , Time Factors
6.
BMJ Qual Saf ; 20(10): 895-902, 2011 Oct.
Article in English | MEDLINE | ID: mdl-21693465

ABSTRACT

BACKGROUND: Narcotics are responsible for many adverse drug events in children and there has been an increase in opioid oversedation events in hospitalised patients. OBJECTIVES: To use improvement methods to prevent perioperative opioid oversedation adverse events while continuing to provide appropriate pain control. METHODS: Interventions included revising the post-anaesthesia order form so that prescribers could choose only one narcotic and one dose for moderate pain and one narcotic and one dose for severe pain, modifying a nursing tool to provide more objective criteria for assessing patient sedation level, and restructuring the pain service. Clinicians on the Acute Pain Service saw all postoperative patients receiving intravenous patient-controlled analgesia or neuraxial narcotics in the mornings and afternoons and a nurse saw them on weekday evenings. RESULTS: The rate of opioid-related oversedation events decreased from 0.15 per 1000 patient days at baseline to 0.111 during the intervention period to 0.074 in the post-intervention period. The days between events increased from 21.0 to 27.5 to 48.8 during the same periods. The number of opioid-related oversedation events decreased from 22 to 17 to 5 during these periods, respectively. CONCLUSIONS: Opioid-related oversedation events decreased over the course of the study. Because the perioperative period is an especially likely time for opioid oversedation events, strict opioid prescribing practices, while maintaining adequate pain control and improved sedation assessment during the perioperative period, were emphasised. The restructured pain service and increased visits by pain team experts were also associated with the reduction in oversedation events.


Subject(s)
Analgesics, Opioid/administration & dosage , Analgesics, Opioid/adverse effects , Perioperative Period , Quality Improvement/organization & administration , Adolescent , Adult , Analgesia, Patient-Controlled/adverse effects , Analgesics, Opioid/therapeutic use , Child , Child, Preschool , Drug Overdose/prevention & control , Female , Hospitals, Pediatric , Humans , Infant , Infant, Newborn , Male , Socioeconomic Factors
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