Targeting zero medication administration errors in the pediatric intensive care unit: A Quality Improvement project.

BACKGROUND: Medication errors and adverse drug events have a significant impact on mortality and morbidity among hospitalized children, and are more likely to occur in critical care settings due to the fast-paced environment and patient vulnerability. There is no exception to this rule in our pediatric intensive care unit, a 28-bed unit at a tertiary care children's hospital in Riyadh, Saudi Arabia. PROBLEM ASSESSMENT: A medication administration error rate of 6.25-8.05/1000 patient days was reported in our unit (48 errors), taking into account only errors that reached patients. Toward improving patient safety, a project was launched to reduce medication errors. DESIGN: Multidisciplinary quality improvement team reviewed baseline data and analyzed medication errors that occurred in 2019. Five Plan-Do-Study-Act cycles were implemented. As an outcome measure, the medication error rate was monitored. RESULTS: The outcome measure of medication administration error rates was monitored quarterly. An improvement of 75% during the first quarter of 2021 to a rate of zero medication errors/1000 patient days during the first quarter of 2022. A decrease in medication errors was attributed to improved situational awareness and increased compliance with assisted technology. CONCLUSION: Medication errors can be decreased by deploying various interventions utilizing human- and technology-based approaches. When it comes to reducing medication errors in the pediatric intensive care unit, a multidisciplinary approach is paramount. IMPLICATIONS FOR CLINICAL PRACTICE: This study suggests several ways to reduce medication errors. Implementing information technology systems and involving pharmacists in medication management can help prevent errors. Enhancing teamwork, communication, and collaboration among healthcare professionals is also important. Clinical risk management strategies, nursing interventions, and adherence to medication safety guidelines are essential, especially for pediatric and neonatal populations. Considering these clinical implications can guide healthcare professionals and organizations in addressing medication errors and enhancing patient safety.

Implementation of a sedation protocol: a quality improvement project to enhance sedation management in the paediatric intensive care unit.

BACKGROUND: Proper sedation is integral to ensuring the safety and comfort of children on mechanical ventilation (MV). Sedation protocols help to achieve this goal and reduce the duration of MV. We have observed varied sedation approaches, sedation score targets and sedative use by our physicians, which were manifested as oversedation and undersedation with associated accidental extubation. Hence, we aimed to implement a standardised sedation protocol and assess its impact on mechanically ventilated paediatric patients. METHODS: A multidisciplinary quality improvement team was formed to develop and implement a standardised sedation protocol for mechanically ventilated paediatric patients. COMFORT-Behaviour (COMFORT-B) Scale score was used to assess the sedation targets and define undersedation, oversedation or adequate sedation. Our goal was to achieve adequate sedation during 90% of the sedation period. Based on the model for improvement methodology, we used plan-do-study-act cycles to develop, test and implement the new sedation protocol. RESULTS: There was an immediate percentage increase in COMFORT-B Scale scores within the target sedation level, which was associated with a gradual decrease in the need for intermittent sedation doses over sedation infusion in the preimplementation, improvement and control phases (6.3, 4.9 and 3.1 sedation doses/12 hours/patient, respectively) to achieve adequate sedation target. CONCLUSIONS: The standardisation of sedation protocols was safe and efficient, and improved the sedation quality in mechanically ventilated paediatric patients.

Association between platelet count and multiorgan dysfunction and outcomes in patients with sepsis in the pediatric intensive care unit in Saudi Arabia.

BACKGROUND: Sepsis is one of the leading causes of morbidity and mortality in the pediatric population worldwide. This study aimed to establish a correlation between platelet count and outcomes of severe sepsis/septic shock in pediatric patients. METHODS: This retrospective cohort study was conducted in the pediatric intensive care unit (PICU) in a pediatric tertiary care medical hospital. Pediatric patients from newborns to 14-year-olds with a diagnosis of sepsis or septic shock who were admitted to the PICU between April 2015 and February 2018 were enrolled. Patients were classified into two groups based on the presence of thrombocytopenia: thrombocytopenia group (TG) with a platelet count <150,000/µL during the first seven days after admission, and non-thrombocytopenia group (NTG) with a platelet count >150,000/µL. RESULTS: Overall, 206 children were enrolled, including 82 (39.8%) in the TG and 124 (60.2%) in the NTG. Thrombocytopenia was more common in patients with a negative bacterial blood culture (93.9%, P = 0.007). NTG was associated with a higher mortality rate (29%) than the TG (12.2%, P = 0.005). Multiorgan dysfunction syndrome (MODS) at the onset of sepsis (time zero) was found to be more prevalent in NTG than in TG (P = 0.001), while the progression of MODS over the three days remained the same in both groups. CONCLUSION: Thrombocytopenia was more associated with non-bacterial sepsis/septic shock, and it may indicate a better outcome of sepsis in pediatric patients.

Elevated intracranial pressure requiring decompressive craniectomy in a child with progressive primary angiitis of the central nervous system: a case report.

BACKGROUND: Elevated intracranial pressure is a potentially catastrophic complication of neurologic injury in children. Successful management of elevated intracranial pressure requires prompt recognition and therapy directed at both reducing intracranial pressure and reversing its underlying cause. A rare condition that causes elevated intracranial pressure is childhood primary angiitis of the central nervous system, which is a rare inflammatory central nervous system disease that poses diagnostic and therapeutic challenges. To our knowledge, this is the first reported case of angiography-positive progressive childhood primary angiitis of the central nervous system requiring decompressive hemicraniectomy for refractory elevated intracranial pressure in children. CASE PRESENTATION: We report the case of a 5-year-old Saudi girl who presented to the pediatric emergency department with fever and new-onset status epilepticus. She had elevated inflammatory markers with radiological and histopathological evidence of angiography-positive progressive childhood primary angiitis of the central nervous system, complicated by elevated intracranial pressure. Despite medical management for both childhood primary angiitis of the central nervous system and elevated intracranial pressure, her neurological status continued to deteriorate and the elevated intracranial pressure became refractory. She developed right uncal, right subfalcine, and tonsillar herniation requiring decompressive hemicraniectomy with a favorable neurological outcome. CONCLUSION: Decompressive craniectomy might be considered in cases of angiography-positive progressive childhood primary angiitis of the central nervous system with elevated intracranial pressure refractory to medication. A multidisciplinary approach for the decision of decompressive craniectomy is advised to ensure patient safety and avoid possible morbidities and mortality.

Leukoreduction and hydroxyurea in malignant pertussis: A case series.

We report five cases of malignant pertussis, a rare but life-threatening illness. Current therapies include supportive care and leukoreduction. Notably, leukoreduction might be more effective when initiated prior to the development of organ failure and pulmonary hypertension.

Association Between Culture-Negative Versus Culture-Positive Sepsis and Outcomes of Patients Admitted to the Pediatric Intensive Care Unit.

Background Sepsis remains a major cause of death, with high mortality and morbidity rates in children. The cause of mortality may be associated with several factors, including differences in cultures and the type of organism. This study was aimed at evaluating the characteristics and outcomes of negative bacterial blood culture compared to those of positive bacterial blood culture in children with severe sepsis/septic shock. Methods A retrospective cohort study was conducted at a pediatric intensive care unit (PICU) of a tertiary care medical center. All pediatric patients, from newborn to 14 years of age, admitted between April 2015 and January 2018 were included in the study if they fulfilled the criteria for severe sepsis/septic shock. Results Of the 209 patients, 30 (14.3%) had a positive bacterial blood culture whereas 179 (86.6%) had a negative bacterial blood culture. Mortality was more in positive bacterial blood culture 13 (43%) vs 35 (20%) in negative bacterial blood culture (P = 0.004). Respiratory tract infections were extremely common, present in 108 of 179 (60%) patients, and tended to result in a negative culture. The rate of organ dysfunction was higher in the positive bacterial blood culture group at admission (P = 0.01). However, the results did not reveal a significant finding related to multiorgan dysfunction syndrome (MODS) progression over three days of PICU admission (P = 0.06). Conclusion The negative bacterial blood culture constitutes a substantial proportion of pediatric patients with severe sepsis/septic shock. Furthermore, these pediatric patients have a lower mortality rate compared to positive bacterial blood cultures. The culture-negative sepsis group also had less organ dysfunction.

Hospital preparedness and management of pediatric population during COVID-19 outbreak.

With the recent pandemic of Coronavirus disease-2019 (COVID-19), there has been a higher number of reported cases in children more than to the prior Corona Virus-related diseases, namely, severe acute respiratory syndrome and the Middle East respiratory syndrome. The rate of COVID-19 in children is lower than adults; however, due to high transmission rate, the number of reported cases in children has been increasing. With the rising numbers among children, it is imperative to develop preparedness plans for the pediatric population at the hospital level, departmental level, and patient care areas. This paper summarizes important considerations for pediatric hospital preparedness at the hospital level that includes workforce, equipment, supply; capacity planning, and infection prevention strategies, it also span over the management of COVID-19 pediatric patients in high-risk areas such as critical care areas, Emergency Department and operative rooms.

Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool.

BACKGROUND: Open communication between leadership and frontline staff at the unit level is vital in promoting safe hospital culture. Our hospital staff culture survey identified the failure to address safety issues as one of the areas where staff felt unable to express their concerns openly. Thus, this improvement project using the daily safety huddle tool has been developed to enhance teamwork communication and respond effectively to patient safety issues identified in a paediatric intensive care unit. METHODS: We used the TeamSTEPPS quality approach. TeamSTEPPS is an evidence-based set of teamwork tools developed by the US Agency of Healthcare Research and Quality to enhance teamwork and communication. We applied TeamSTEPPS using a tool called the Daily Safety Huddle, aiming at improving communication and interaction between healthcare workers and building trust by acting immediately when there is any patient safety issue or concern at the unit level. RESULTS: During the period from April to December 2017, the interaction between frontline staff and unit leadership increased through compliance with the daily safety huddle. Initially, compliance was at 73%, but it increased to 97%, with a total of 340 safety issues addressed. The majority of these safety issues pertained to infection control and medication errors (109; 32.05%), followed by communication (83; 24.41%), documentation (59; 17.35%), other issues (37; 10.88%), procedure (20; 5.88%), patient flow (16; 4.7%) and equipment and supplies (16; 4.7%). CONCLUSIONS: Systematic use of daily safety huddle is a powerful tool to create an equitable environment where frontline staff can speak up freely about daily patient safety concerns. The huddle leads to a more open and active discussion with unit leadership and to the ability to perform the right action at the right time.

Improving physician handover documentation process for patient transfer from paediatric intensive care unit to general ward.

BACKGROUND: Inadequate handover communication is responsible for many adverse events during the transfer of care, which can be attributed to many factors, including incomplete documentation or lack of standardised documentation process. The quality improvement project aimed to standardise the handover documentation process during patient transfer from paediatric intensive care unit (PICU) to the general paediatric ward. METHODS: Data analysis revealed lack of proper handover documentation with the omission of vital information when transferring patients from PICU to general ward. The quality improvement team assessed the current handover documentation practice using a brainstorming technique during multiple meetings. The team evaluated the process for possible causes of incomplete handover documentation, framed the existing challenges, and proposed improvement interventions, including a standardised handover form and conducting education sessions for the new proposed process. The main quality measures included physician's compliance with handover documentation elements, physician's satisfaction and PICU emergency readmission rate within 48 hours. RESULTS: Physician compliance to handover documentation improved from 29.5% to 95.5% before and after implanting the improvement interventions, respectively. The level of physician satisfaction with the quality of communicated information during the handover process improved from 47.5% to 84%, and the PICU emergency readmission rate declined from 3.8% to zero after all improvement interventions were implanted. CONCLUSION: Implementation of standardised handover form is essential to improve physician compliance for clear handover documentation and to avoid data omission during the patient transfer process. Documented handover in patient's medical record has positive impact on physician satisfaction when managing patients recently discharged from PICU.

Reducing unnecessary delays during the transfer of patients from the paediatric intensive care unit to the general ward: a quality improvement project.

INTRODUCTION: Delaying the discharge of paediatric intensive care unit (PICU) patients is directly proportional to increased occupancy rate and cost. We aimed to study the process of transferring patients from the PICU to the general ward in order to improve the timeliness of this process while guaranteeing patient safety. METHODS: A multidisciplinary quality improvement (QI) team was formed to analyse the transfer process. Several Plan Do Study Act cycles were tested, targeting all steps of the transfer process, and applying turnaround time (TAT)-the duration from the time of clinical transfer decision until the physical transfer of the patient-as an outcome measure, aiming for a TAT of 4 hours. RESULTS: Baseline results showed that medical transfer decisions by PICU attending physicians were taken late for most patients: only 19% of decisions were made by 08:00 by the on-call team. Average TAT of the transfer process was over 7 hours, with duration ranging from 7 to 17 hours. After implementing all suggested improvement interventions, early decision compliance improved to 59%. TAT improved gradually, starting in January 2017, until it approached our target (284-261 min≈4 hours) in February-May 2017. CONCLUSION: PICU patient transfer process delays can be reduced by early evaluation, timely team communication and proper preparation. It is recommended that all personnel with early involvement avoid unnecessary delays by paying more attention to all process steps, starting with the clinical decision, until the physical transfer. Standardising transfer processes might lead to a decrease in the length of PICU stay, which is a desirable outcome, but this observation needs further exploration.

Primary Giant Cerebral Hydatid Cyst in an 8-year-old Girl.

Echinococcosis, also called hydatid disease, is a parasitic disease that passes from animals to humans. Literature reports suggest very rare cases of cerebral hydatid cysts. Brain involvement with hydatid disease occurs in 1%-2% of all Echinococcus infections. In this report, we aim to emphasize the presentation of such an isolated primary cerebral hydatid cyst, discuss its radiological features, Emergency department management, inpatient medical management, referral to neurosurgery, consequent operative procedures, postoperative care, and outcome.