Evaluation of the Efficacy of a Hypoglycemia Protocol to Treat Severe Hypoglycemia.

PURPOSE: The purpose of this quality improvement project was to evaluate the efficacy of the facility's Hypoglycemia Protocol when treating severe hypoglycemia (defined as blood glucose < 50 mg/dL). DESCRIPTION: The diabetes clinical nurse specialists conducted a retrospective chart review of diabetic inpatients with severe hypoglycemia who were treated per the Hypoglycemia Protocol from October 1, 2017, through April 30, 2019. The primary outcome was achievement of euglycemia (defined as blood glucose ≥ 80 mg/dL) 15 to 30 minutes post treatment with either oral carbohydrates or intravenous dextrose. OUTCOME: Two hundred twenty-two patients received treatment with oral carbohydrates versus 120 patients who received intravenous dextrose. Fifty patients receiving oral carbohydrates versus 106 patients receiving intravenous dextrose achieved euglycemia after 1 treatment. Compared with treatment with intravenous dextrose, the odds ratio of the rise in blood glucose to 80 mg/dL or greater within 15 to 30 minutes post treatment for a patient given oral carbohydrate was decreased by 97.2%. CONCLUSION: Intravenous dextrose was more efficacious than oral carbohydrate treatment in patients with diabetes experiencing severe hypoglycemia. In response, the Hypoglycemia Protocol was revised to increase oral carbohydrate treatment for severe hypoglycemia and to expedite escalation from oral to intravenous treatment.

Low-Dose Donor Dopamine Is Associated With a Decreased Risk of Right Heart Failure in Pediatric Heart Transplant Recipients.

BACKGROUND: Previous studies in adults have suggested that donor dopamine treatment may improve recipient outcomes in organ transplantation; in this analysis, we aimed to determine if donor dopamine reduces the incidence of postoperative right heart failure (RHF) in pediatric heart transplant recipients. METHODS: Data for recipients aged 18 years or younger transplanted at our institution between January 1, 2000, and June 15, 2011, and their respective donors were obtained. The presence of postoperative RHF was assessed for in all subjects. Donor dopamine dose was stratified into 3 groups: none, low-dose (≤5 µg/kg per minute), and high-dose (>5 µg/kg per minute). Logistic regression was used to assess the relationship between donor dopamine dose and recipient RHF. RESULTS: Of 192 recipients, 34 (18%) experienced postoperative RHF. There was no difference in baseline demographics between recipients with and without RHF. When controlling for pulmonary vascular resistance index, graft ischemic time, and cardiopulmonary bypass time, donor low-dose dopamine was independently associated with a decreased risk of RHF (odds ratio, 0.16; 95% confidence interval, 0.04-0.70; P = 0.02); however high-dose dopamine was neither associated with, nor protective of, RHF (odds ratio, 0.31; 95% confidence interval, 0.06-1.6; P = 0.16). CONCLUSIONS: Despite advances in perioperative care of the recipient, RHF persists as a complication of pediatric heart transplantation. In this study, donor pretreatment with low-dose dopamine is associated with a decreased risk of postoperative RHF in pediatric heart recipients. Further studies into this association may be useful in determining the utility of empiric donor pretreatment with low-dose dopamine.

Effect of a Brief Massage on Pain, Anxiety, and Satisfaction With Pain Management in Postoperative Orthopaedic Patients.

BACKGROUND: The majority of massage therapy studies have evaluated 20- to 45-minute interventions in nonsurgical patients. Studies are needed to evaluate the effects of a brief massage intervention that would be more clinically feasible for bedside clinicians to administer as an adjunct to pharmacologic pain management in acutely ill surgical patients. PURPOSE: To evaluate the impact of a brief massage intervention in conjunction with analgesic administration on pain, anxiety, and satisfaction with pain management in postoperative orthopaedic inpatients. METHODS: A convenience sample of postoperative orthopaedic patients was studied during two therapeutic pain treatments with an oral analgesic medication. A pretest, posttest, randomized, controlled trial study design, with crossover of subjects, was used to evaluate the effect of a 5-minute hand and arm massage at the time of analgesic administration. Each patient received both treatments (analgesic administration alone [control]; analgesic administration with massage) during two sequential episodes of postoperative pain. Prior to administration of the analgesic medication, participants rated their level of pain and anxiety with valid and reliable tools. Immediately after analgesic administration, a study investigator provided the first, randomly assigned treatment. Pain and anxiety were rated by the participant 5 and 45 minutes after medication administration. Satisfaction with pain management was also rated at the 45-minute time point. Study procedures were repeated for the participant's next requirement for analgesic medication, with the participant receiving the other randomly assigned treatment. Analysis of variance was used to determine whether pain, anxiety, and/or satisfaction with pain management differed between the two treatment groups and/or if treatment order was a significant factor. The level of significance for all tests was set at p < .05. RESULTS: Twenty-five postoperative patients were studied during two sequential episodes of pain, which required analgesic medication administration (N = 25 analgesic alone; N = 25 analgesic with massage). Patient ages ranged from 32 to 86 years (average ±SD = 61.2 ± 11.5 years). Pain and anxiety scores after medication administration decreased in both groups, with no significant differences found between the analgesic alone or analgesic with massage treatments (p > .05). Patient satisfaction with pain management was higher for pain treatment with massage than medication only (F = 6.8, df = 46, p = .012). CONCLUSION: The addition of a 5-minute massage treatment at the time of analgesic administration significantly increased patient satisfaction with pain management.

Policy and system change and community coalitions: outcomes from allies against asthma.

Objectives. We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. Methods. We interviewed a sample of 1,477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. Results. A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. Conclusions. Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Principles to guide sustainable implementation of extended-scope-of-practice physiotherapy workforce redesign initiatives in Australia: stakeholder perspectives, barriers, supports, and incentives.

Sustainable implementation of new workforce redesign initiatives requires strategies that minimize barriers and optimize supports. Such strategies could be provided by a set of guiding principles. A broad understanding of the concerns of all the key stakeholder groups is required before effective strategies and initiatives are developed. Many new workforce redesign initiatives are not underpinned by prior planning, and this threatens their uptake and sustainability. This study reports on a cross-sectional qualitative study that sought the perspectives of representatives of key stakeholders in a new workforce redesign initiative (extended-scope-of-practice physiotherapy) in one Australian tertiary hospital. The key stakeholder groups were those that had been involved in some way in the development, management, training, funding, and/or delivery of the initiative. Data were collected using semistructured questions, answered individually by interview or in writing. Responses were themed collaboratively, using descriptive analysis. Key identified themes comprised: the importance of service marketing; proactively addressing barriers; using readily understood nomenclature; demonstrating service quality and safety, monitoring adverse events, measuring health and cost outcomes; legislative issues; registration; promoting viable career pathways; developing, accrediting, and delivering a curriculum supporting physiotherapists to work outside of the usual scope; and progression from "a good idea" to established service. Health care facilities planning to implement new workforce initiatives that extend scope of usual practice should consider these issues before instigating workforce/model of care changes.

Hypoalbuminemia and poor growth predict worse outcomes in pediatric heart transplant recipients.

Children with end-stage cardiac failure are at risk of HA and PG. The effects of these factors on post-transplant outcome are not well defined. Using the PHTS database, albumin and growth data from pediatric heart transplant patients from 12/1999 to 12/2009 were analyzed for effect on mortality. Covariables were examined to determine whether HA and PG were risk factors for mortality at listing and transplant. HA patients had higher waitlist mortality (15.81% vs. 10.59%, p = 0.015) with an OR of 1.59 (95% CI 1.09-2.30). Survival was worse for patients with HA at listing and transplant (p ≤ 0.01 and p = 0.026). Infants and patients with congenital heart disease did worse if they were HA at time of transplant (p = 0.020 and p = 0.028). Growth was poor while waiting with PG as risk factor for mortality in multivariate analysis (p = 0.008). HA and PG are risk factors for mortality. Survival was worse in infants and patients with congenital heart disease. PG was a risk factor for mortality in multivariate analysis. These results suggest that an opportunity may exist to improve outcomes for these patients by employing strategies to mitigate these risk factors.

Asthma coalition effects on vulnerable sub groups of children: the most frequent users of health care and the youngest.

OBJECTIVE: To examine the impact of Allies Against Asthma, community-based coalitions working to improve asthma outcomes, on vulnerable children: those with the most urgent health care use and those of youngest age. METHODS: Allies zip codes were matched with comparison communities on demographic factors. Five years of Medicaid data (n = 26,836) for significant health care events: hospitalizations, ED and urgent care facility visits, were analyzed. Longitudinal analyses using generalized estimating equations and proportional hazards models compared Allies and comparison group children. RESULTS: In the two start-up years of Allies, odds of having a significant event were greater for Allies children than for comparison children (p < 0.05). During the third and fourth years when Allies activities were fully implemented, for frequent health care users at baseline, odds of an asthma event were the same for both Allies and comparison children, yet in the less frequent users, odds of an event were lower in Allies children (p < 0.0001). In the initial year of Allies efforts, among the youngest, the Allies children had greater odds than comparison children of an event (p < 0.01), but by the fourth year the Allies group had lower odds (p = 0.02) of an event. Hazard ratios over all years of the study for the youngest Allies children and most frequent baseline users of urgent care were lower than for comparison children (p = 0.01 and p = 0.0004). CONCLUSION: Mobilizing a coalition of diverse stakeholders focused on policy and system change generated community-wide reductions over the long-term in health care use for vulnerable children.

Implementation of a diabetes prevention program in public housing communities.

OBJECTIVE: The purpose of this study was to describe the process of implementing a diabetes prevention program provided by homecare nurses to residents of public housing communities. DESIGN AND SAMPLE: A cluster randomization pilot study was conducted comparing enhanced standard care (2 interactive classes on diabetes prevention) to a diabetes prevention program (7 interactive classes and behavioral support). The sample (n = 67) was primarily female (79%), nonwhite (76%), unpartnered (83%), with a mean age of 40 years, and an average of 3 children. Mixed methods were used to evaluate the implementation process. MEASURES: Data were collected on attendance, attrition, and protocol implementation. Interviews were conducted with nurses and community health workers who assisted with program implementation. RESULTS: Homecare nurses were able to implement a diabetes prevention program in public housing communities, with a protocol implementation of 83% across classes and groups. Attendance was suboptimal with 60% for the enhanced standard care group and 54% for the diabetes prevention group. Nurses and community health workers were resourceful and positive about program implementation. CONCLUSION: Linking existing resources, such as a homecare agency with a public housing community, is one approach to disseminate diabetes prevention programs.

Left ventricular assist device to avoid heart-lung transplant in an adolescent with dilated cardiomyopathy and severely elevated pulmonary vascular resistance.

Orthotopic heart transplantation remains the definitive treatment of choice for patients with end-stage heart failure; however, elevated PVRI is a reported risk factor for mortality after heart transplant and, when severely elevated, is considered an absolute contraindication. Use of a ventricular assist device has been proposed as one treatment for reducing pulmonary vascular resistance index in potential heart transplant candidates refractory to medical vasodilator therapies. We report on a teenage patient with dilated cardiomyopathy and severely elevated PVRI, unresponsive to pulmonary vasodilator therapy, who underwent left ventricular assist device implantation to safely allow for aggressive pulmonary vasodilator therapy and to decrease PVRI. The resulting dramatic improvement in PVRI in a relatively short period of time allowed for successful heart transplantation, avoiding the need for heart-lung transplant.

Improvements in health care use associated with community coalitions: long-term results of the allies against asthma initiative.

OBJECTIVES: We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control. METHODS: Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model. RESULTS: In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use. CONCLUSIONS: Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities.

A comparison of traditional versus contemporary immunosuppressive regimens in pediatric heart recipients.

OBJECTIVES: To assess the differences in rejection and infection complications between the most common contemporary immunosuppression regimen in pediatric heart transplantation (cytolytic induction, tacrolimus based) and classic triple-therapy (cyclosporine based without induction). STUDY DESIGN: We performed a retrospective, historical-control, observational study comparing outcomes in patients who underwent traditional immunosuppression (control group, n = 64) with those for whom the contemporary protocol was used (n = 39). Episodes of rejection, viremia (cytomegalovirus or Epstein-Barr virus), serious bacterial or fungal infections, anemia or neutropenia requiring treatment in the first year after heart transplantation, and 1-year survival were compared between traditional and contemporary immunosuppression groups. RESULTS: The 2 groups were similar with respect to baseline demographics. There were no differences in risk of cytomegalovirus, Epstein-Barr virus, or bacterial or fungal infections in the first year post-transplantation. Patients in the contemporary group were more likely to need therapy for anemia (51% vs 14%, P < .001) or neutropenia (10% vs 0%, P = .019). However, more contemporary protocol patients were rejection-free in the first year post-transplantation (63% vs 41%, P = .03). Overall graft survival was similar between groups (P = .15). CONCLUSIONS: A contemporary immunosuppression regimen using tacrolimus, mycophenolate mofetil, and induction was associated with less rejection in the first year, with no difference in the risk of infection but greater risk of anemia and neutropenia requiring treatment. Long-term follow-up on these patients will evaluate the impact of the immunosuppression regimen on survival.

Management of intracranial hemorrhage in a child with a left ventricular assist device.

Pediatric patients bridged to heart transplant with LVADs require chronic anticoagulation and are at increased risk of hemorrhagic complications, including intracranial hemorrhage. In this population, intracranial hemorrhage is often fatal. We report a case of successful management of a five-yr-old-boy with DCM on an LVAD who developed a subdural hematoma. We initially chose medical management, weighing the patient's high risk of thromboembolism from anticoagulation reversal against the risk of his chronic subdural hematoma. When head CT showed expansion of the hemorrhage with increasing midline shift, we chose prompt surgical evacuation of the hematoma with partial reversal of anticoagulation, given the increased risk of acute deterioration. The patient ultimately received an orthotopic heart transplant and was discharged with no permanent neurological complications. This represents a case of a pediatric patient on an LVAD who survived a potentially fatal subdural hematoma and was successfully bridged to cardiac transplantation.

A decade of pediatric mechanical circulatory support before and after cardiac transplantation.

OBJECTIVES: We reviewed the use of pediatric mechanical circulatory support before and after transplantation to examinine current results and future strategies. METHODS: All patients listed for transplantation from January 2000 to December 2010 who required either extracorporeal membrane oxygenation (ECMO) or ventricular assist device (VAD) support before ("intention to transplant") or after transplantation were included. Indications for mechanical assistance, age, weight, duration of support, complications while on support, causes of death, and overall actuarial survival were recorded. RESULTS: Thirty-seven patients were received VADs; 32 (86.5%) survived to transplantation. Postoperative hemorrhagic or thrombotic complications affected all of those under 15 kg. One patient in the survivor cohort demonstrated focal neurologic findings. Three (8.1%) had panel reactive antibody levels of 10% or more while on device support; all received transplants. ECMO as an intention to bridge to transplantation was used in 28 patients; 7 died, 7 were weaned, and 14 were bridged to transplantation. Nineteen patients required ECMO after transplantation; 3 additional patients had percutaneous VAD support for late rejection. There was a significant (P = .02) difference in survival after listing for transplantation among those supported with ECMO, with VAD, and those not supported with a device. No difference in posttransplant survival was demonstrated between those patients supported with either ECMO or VAD before transplant compared with all others not bridged to transplantation. CONCLUSIONS: Both VAD and ECMO support are highly effective means of bridging patients to transplantation and supporting patients after transplanatation. Ideally, the availability of smaller devices for children will have a favorable impact on the morbidity related to anticoagulation in the smallest patients.

Effectiveness of a physiotherapy-initiated telephone triage of orthopedic waitlist patients.

BACKGROUND: There is generally a lengthy wait on outpatient orthopedic waiting lists in Australian public hospitals to consult a specialist. Patients then wait again for surgery, if required. Patients with higher need are rarely prioritized, and there is the potential for increased morbidity for those who wait. There is generally no option of alternative care whilst waiting. This paper compares historical orthopedic outpatient clinic data with the outcomes of a physiotherapy-led initiative in one large Australian tertiary hospital. METHODS: Two physiotherapists working within-scope conducted a telephone triage (October to December 2010) using a standard instrument for all new patients on the orthopedic waiting list. They were offered primary treatment options of retaining their appointment, being discharged, referral to a new model of assessment (multidisciplinary specialist clinic), or referral to physiotherapy. The outcomes were costs of the service, waiting time, and percentage of patients taking up management options. This was compared with a historical sample of new patients on the orthopedic waiting list (January to March 2009), whose treatment consumption was tracked longitudinally. RESULTS: The telephone triage resulted in 16.4% patients being discharged directly (compared with 0.1% comparison sample). For approximately AU$17.00 per patient, the telephone triage process released 21 booked appointments on the outpatient clinic waiting list. Moreover, approximately 26% patients were referred directly to physiotherapy, which was not a primary management option in the comparison sample. The waiting time for an appointment, for those patients who remained on the waiting list, was significantly shorter for the telephone triage sample than the comparison sample. There were significantly higher rates of failure to attend appointments, and significantly lower rates of discharge, in the comparison sample, than the telephone triage sample. CONCLUSION: A physiotherapist-led intervention offering alternative management options whilst patients waited for an orthopedic outpatient clinic consultation appears to be cost-effective, and patient-centered.

Policy and system change and community coalitions: outcomes from allies against asthma.

OBJECTIVES: We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. METHODS: We interviewed a sample of 1477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. RESULTS: A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. CONCLUSIONS: Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

From formation to action: How allies against asthma coalitions are getting the job done.

Coalitions develop in and recycle through stages. At each stage (formation, implementation, maintenance, and institutionalization), certain factors enhance coalition function, accomplishment of tasks, and progression to the next stage. The Allies Against Asthma coalitions assessed stages of development through annual member surveys, key informant interviews of 16 leaders from each site, and other evaluation tools. Results indicate all coalitions completed formation and implementation, six achieved maintenance, and five are in the institutionalization stage. Differences among coalitions can be attributed to their maturity and experience working within a coalition framework. Participants agreed that community mobilization around asthma would not have happened without coalitions. They attributed success to being responsive to community needs and developing comprehensive strategies, and they believed that partners' goals were more innovative and achievable than any institution could have created alone.