Pediatric Cardiothoracic Intensive Care Unit Research Articles

Increasing the Percentage of Neonates Consuming Human Milk in a Pediatric Cardiothoracic Intensive Care Unit: A Quality Improvement Initiative

To address a known nutritional deficit and enhance the overall health of critically ill babies, this project sought to increase the percentage of cardiothoracic intensive care unit (CTICU) neonates consuming human milk from a 2019 baseline of 55% to 75% by December 2020 and 90% by December2021. This was a quality improvement initiative targeted to all neonates admitted to the CTICU, with baseline data obtained from January 2019 through February 2020. We implemented 11 interventions from March 2020 to January 2022 to address the key drivers of "education of parents and providers," "environment/equipment," and "process." We tracked the monthly percentage of neonates who were human milk fed with a statistical process control p-chart. The balancing measure of critical human milk feeding errors was also monitored. The baseline percentage of CTICU neonates consuming human milk was 55%. This percentage increased to 73% by the end of 2020 and 92% by the year end 2021. Most neonates who received human milk were fed mother's milk with a minority receiving donor human milk. The number of aborted, critical human milk administration errors decreased during the intervention period. In this quality improvement initiative, we significantly increased the percentage of CTICU neonates consuming human milk without an increase in critical human milk errors. Interventions directly increasing the ease with which lactating mothers can provide/store their milk were likely the most effective.

Reduced Intracranial Hemorrhage with Anticoagulation Guideline Implementation.

Hemorrhagic and thrombotic complications, including intracranial hemorrhage, embolic stroke, surgical bleeding, and circuit thrombosis, are common during extracorporeal membrane oxygenation (ECMO), occurring in up to 50% of patients. These complications have a significant impact on morbidity and mortality. Our objective was to implement standardized ECMO anticoagulation guidelines for the pediatric cardiothoracic intensive care unit (CTICU) to reduce the incidence of intracranial hemorrhage while on ECMO. All CTICU patients who received ECMO from January 2016 to December 2020 were retrospectively reviewed. Standardized ECMO anticoagulation guidelines were implemented in the fourth quarter of 2017. Variables and clinical outcomes before and after guideline implementation were compared. From January 2016 to December 2017, there were 22 separate ECMO runs. Eight of 22 (36%) suffered intracranial hemorrhage while on ECMO. Seven of 8 (88%) were withdrawn from ECMO secondary to bleed and expired prior to hospital discharge. From January 2018 to December 2020, there were 22 separate ECMO runs in the CTICU. Three of 22 (14%) suffered intracranial hemorrhage while on ECMO. One of 3 (33%) expired prior to hospital discharge. Implementation of standardized ECMO anticoagulation guidelines in the CTICU was successful in improving clinical outcomes as evidenced by reduction in the incidence of intracranial hemorrhage in this high-risk patient population.

Reduced Intracranial Hemorrhage with Anticoagulation Guideline Implementation

Hemorrhagic and thrombotic complications, including intracranial hemorrhage, embolic stroke, surgical bleeding, and circuit thrombosis, are common during extracorporeal membrane oxygenation (ECMO), occurring in up to 50% of patients. These complications have a significant impact on morbidity and mortality. Our objective was to implement standardized ECMO anticoagulation guidelines for the pediatric cardiothoracic intensive care unit (CTICU) to reduce the incidence of intracranial hemorrhage while on ECMO. All CTICU patients who received ECMO from January 2016 to December 2020 were retrospectively reviewed. Standardized ECMO anticoagulation guidelines were implemented in the fourth quarter of 2017. Variables and clinical outcomes before and after guideline implementation were compared. From January 2016 to December 2017, there were 22 separate ECMO runs. Eight of 22 (36%) suffered intracranial hemorrhage while on ECMO. Seven of 8 (88%) were withdrawn from ECMO secondary to bleed and expired prior to hospital discharge. From January 2018 to December 2020, there were 22 separate ECMO runs in the CTICU. Three of 22 (14%) suffered intracranial hemorrhage while on ECMO. One of 3 (33%) expired prior to hospital discharge. Implementation of standardized ECMO anticoagulation guidelines in the CTICU was successful in improving clinical outcomes as evidenced by reduction in the incidence of intracranial hemorrhage in this high-risk patient population.

Arrhythmia In Postoperative Period After Cardiac Surgery for Congenital Heart Disease In Zagazig Children Hospital

Background: Arrhythmias occur often in the early postoperative period, where hemodynamic variations are normal, rendering the patient unstable and can lead to low cardiac output and cardiac arrest unless treated and resolved in a timely manner. The aim of this study was to analyze the possible causes and risk factors of early arrhythmias to determine the outcome of patients and prevention of arrhythmias after congenital cardiac surgery in pediatrics. Methods: This Prospective observational study was conducted in pediatric cardiothoracic intensive care unit (ICU) and pediatric cardiology unit of Zagazig university, the target sample included 24 patients

Guidelines for Diuretic Utilization Reduce High Charge Medications.

Background:Decreasing practice variation and following evidence-based clinical guidelines improve patient outcomes and often reduce cost. Essentially all postsurgical cardiac patients require diuretics. The approach to diuresis in the pediatric cardiothoracic intensive care unit (CTICU) is not standardized. Our objective was to develop and implement guidelines for diuretic utilization in the CTICU to reduce high charge medication utilization while maintaining the delivery of high-quality care.Methods:Two of the top 10 medications by charge in the CTICU during 2016 were diuretics [fenoldopam and intravenous (IV) chlorothiazide]. Standardized diuretic utilization guidelines were developed to reduce the utilization of fenoldopam and IV chlorothiazide. We implemented guidelines in April 2017. The utilization of fenoldopam and IV chlorothiazide, as well as overall diuretic charges, before and after guideline implementation were compared.Results:We normalized all comparisons to 100 CTICU patient-days. Fenoldopam starts were reduced from 1.1 in 2016 to 0.03 in 2019 (through February); days of fenoldopam use were reduced from 4 in 2016 to 0.15 days in 2019 (through February); IV chlorothiazide doses decreased from 20 in 2016 to 8 in 2019 (through February). These changes reduced the mean charges for diuretics from $25,762 in 2016 to $8,855 in 2019 (through February). CTICU average daily census did not change significantly during the study period (12.8 in 2016 vs 11.8 in 2018).Conclusion:Value-added implementation of standardized diuretic utilization guidelines in the CTICU successfully reduced the use of high-charge diuretics without unfavorably impacting the quality of care delivery.

The Role of Extracorporeal Membrane Oxygenation Simulation Training at Extracorporeal Life Support Organization Centers in the United States.

Extracorporeal membrane oxygenation (ECMO) requires a multidisciplinary healthcare team. The Extracorporeal Life Support Organization publishes training guidelines but leaves specific requirements up to each institution. Simulation training has shown promise, but it is unclear how many institutions have incorporated simulation techniques into ECMO training to date. We sent an electronic survey to ECMO coordinators at Extracorporeal Life Support Organization sites in the United States. Participants were asked about training practices and the use of simulation for ECMO training. Descriptive results were reported as the percentage of total responses for each question. Logistic regression was used to identify characteristics associated with simulation use. Of 94 responses (62% response rate), 46% had an ECMO simulation program, whereas 26% report a program is in development. Most (61%) have been in operation for 2 to 5 years. Sixty-three percent use simulation for summative assessment, and 76% have multidisciplinary training. Access to a simulation center [odds ratio (OR) = 4.7, 95% confidence interval (CI) = 1.7-12.5], annual ECMO caseload of greater than 20 (OR = 2.5, 95% CI = 1.5-5.8), and having a pediatric cardiothoracic intensive care unit (OR = 2.8, 95% CI = 1.2-6.7) are each associated with increased likelihood of mannequin-based ECMO simulation. Common scenarios include pump failure (93%), oxygenator failure (90%), and circuit rupture (76%). Extracorporeal membrane oxygenation simulation is growing but remains in its infancy. Centers with access to a simulation center, higher caseloads, and pediatric cardiothoracic intensive care units are more likely to have ECMO simulation programs. Extracorporeal membrane oxygenation simulation is felt to be beneficial, and further work is needed to delineate best training practices for ECMO providers.

Comparing Administrative and Clinical Data for Central Line Associated Blood Stream Infections in Pediatric Intensive Care Unit and Pediatric Cardiothoracic Intensive Care Unit

Central line associated bloodstream infections (CLABSIs) are a frequent source of health complication for patients of all ages, including for patients in the pediatric intensive care unit (PICU) and Pediatric Cardiothoracic Intensive Care Unit (PCTU). Many hospitals, including the University of Michigan Health System, currently use the International Classification of Disease (ICD) coding system when coding for CLABSI.The purpose of this study was to determine the accuracy of coding for CLABSI infections with ICD-9CM codes in PICU and PCTU patients. A retrospective chart review was conducted for 75 PICU and PCTU patients with 90 events of hospital acquired central line infections at the University of Michigan Health System (from 2007-2011). The different variables examined in the chart review included the type of central line the patient had, the duration of the stay of the line, the type of organism infecting the patient, and the treatment the patient received. A review was conducted to assess if patients had received the proper ICD-9CM code for their hospital acquired infection. In addition, each patient chart was searched using Electronic Medical Record Search Engine to determine if any phrases that commonly referred to hospital acquired CLABSIs were present in their charts. Our review found that in most CLABSI cases the hospital’s administrative data diagnosis using ICD-9CM coding systems did not code for the CLABSI. Our results indicate a low sensitivity of 32% in the PICU and an even lower sensitivity of 12% in the PCTU. Using these results, we can conclude that the ICD-9CM coding system cannot be used for accurately defining hospital acquired CLABSIs in administrative data. With the new use of the ICD-10CM coding system, further research is needed to assess the effects of the ICD-10CM coding system on the accuracy of administrative data.

Shared Governance for a Healthy Work Environment in a Pediatric Cardiothoracic Intensive Care Unit.

Shared Governance for a Healthy Work Environment in a Pediatric Cardiothoracic Intensive Care Unit.

Increasing parental participation during rounds in a pediatric cardiac intensive care unit.

Inviting parents of sick children to participate during the rounding process may reduce parents' anxiety and improve communication between the parents and the health care team. To increase the percentage of available parents invited to participate in morning rounds in a pediatric cardiothoracic intensive care unit (CTICU). Invitations to parents to participate in morning CTICU rounds were randomly audited from June 2012 to April 2014 (mean, 15 audits per month). From June 2012 to February 2013 (before intervention), 73% of parents available during morning rounds received an invitation to participate. From April 2013 to May 2013, the following interventions (family participation bundle) were implemented: (1) staff education, (2)"Invitation to Rounds" handout added to the parent welcome packet with verbal explanation, (3) bedside tool provided for parents to communicate desire to participate in rounds with the team, (4) reminder to invite parents added to nursing rounding sheet. Following interventions, family feedback was obtained by 1-on-1 (physician-parent) open-ended conversation. From April 2013 to April 2014, 94% of parents available during morning rounds received an invitation to participate. Reasons for not participating: chose not to participate (63%), sleeping-staff reluctant to wake (25%), not English speaking (7%), breastfeeding (5%). Implementation of a family participation bundle was successful in increasing invitations to parents to participate during morning rounds in the CTICU. Engagement of staff and addressing specific staff concerns was instrumental in the project's success.

Reduction of medication errors in a pediatric cardiothoracic intensive care unit.

Medication errors resulting in patient harm were reduced from 33 in 2010 to 3 in 2011, 6 in 2012, and 4 in 2013 by initiating the following quality improvement interventions: multidisciplinary cardiothoracic intensive care unit quality committee, nursing education, shift change medication double check, medication error huddles, safety systems checklist, distraction-free zone to enter orders, and medication bar coding.

Perceptions of 24/7 In-house Attending Coverage on Fellow Education and Autonomy in a Pediatric Cardiothoracic Intensive Care Unit.

The 24/7 in-house attending coverage is emerging as the standard of care in intensive care units. Implementation costs, workforce feasibility, and patient outcomes resulting from changes in physician staffing are widely debated topics. Understanding the impact of staffing models on the learning environment for medical trainees and faculty is equally warranted, particularly with respect to trainee education and autonomy. This study aims to elicit the perceptions of pediatric cardiology fellows and attendings toward 24/7 in-house attending coverage and its effect on fellow education and autonomy. We surveyed pediatric cardiology fellows and attendings practicing in the pediatric cardiothoracic intensive care unit (PCTU) of a large, university-affiliated medical center, using structured Likert response items and open-ended questions, prior to and following the transition to 24/7 in-house attending coverage. All (100%) trainees and faculty completed all surveys. Both prior to and following transition to 24/7 in-house attending coverage, all fellows, and the majority of attendings agreed that the overnight call experience benefited fellow education. At baseline, trainees identified limited circumstances in which on-site attending coverage would be critical. Preimplementation concerns that 24/7 in-house attending coverage would negatively affect the education of fellows were not reflected following actual implementation of the new staffing policy. However, based upon open-ended questions, fellow autonomy was affected by the new paradigm, with fellows and attendings reporting decreased "appropriateness" of autonomy after implementation. Our prospective study, showing initial concerns about limiting the learning environment in transitioning to 24/7 in-house attending coverage did not result in diminished perceptions of the educational experience for our fellows but revealed an expected decrease in fellow autonomy. The study indirectly facilitated open discussions about methods to preserve fellow education and warranted autonomy in our PCTU; however, continued efforts are needed to achieve the optimal balance between supervised training and the transition to autonomous practice.

Utility of a Clinical Practice Guideline in Treatment of Chylothorax in the Postoperative Congenital Heart Patient

Chylothorax after congenital heart surgery is a common complication with associated morbidities, but consensus treatment guidelines are lacking. Variability exists in the duration of medical treatment and timing for surgical intervention. After institution of a clinical practice guideline for management of postoperative chylothorax at a single center, pediatric cardiothoracic intensive care unit (ICU) in June 2010, we retrospectively analyzed 2 cohorts of patients: those with chylothorax from January 2008 to May 2010 (early cohort; n=118) and from June 2010 to August 2011 (late cohort; n=45). Data collected included demographics, cardiac surgical procedure, treatments for chylothorax, bloodstream infections, hospital mortality, length of hospitalization, duration of mechanical ventilation, and device utilization. There were no demographic differences between the cohorts. No differences were found in octreotide use or surgical treatments for chylothorax. Significant differences were found in median times to chylothorax diagnosis (9 in early cohort versus 6 days in late cohort, p=0.004), ICU length of stay (18 vs 9 days, p=0.01), hospital length of stay (30 vs 23 days, p=0.005), and total durations of mechanical ventilation (11 vs 5 days, p=0.02), chest tube use (20 vs 14 days, p=0.01), central venous line use (27 vs 15 days, p=0.001), and NPO status (9.5 vs 6 days, p=0.04). Institution of a clinical practice guideline for treatment of chylothorax after congenital heart surgery was associated with earlier diagnosis, reduced hospital length of stay, mechanical ventilation, and device utilization for these patients.

Predictors of acute kidney injury post-cardiopulmonary bypass in children

To investigate the incidence, implicating factors and outcome of acute kidney injury (AKI) after cardiopulmonary bypass (CPB) in patients admitted to a pediatric cardiothoracic intensive care unit (ICU). A retrospective review study. A 10-bed cardiothoracic ICU. One hundred and twenty-four children (<18 years of age) admitted to the cardiothoracic ICU following CPB between January 2007 and December 2009. Age, sex, diagnosis, baseline and post-surgery hemoglobin, total leukocyte count, platelet count and biochemistry were recorded. Baseline and postoperative urea (mg/dl), creatinine (mg/dl), urine output (ml/kg/h) and inotrope dose were also recorded daily. The duration of CPB was noted. Postoperative cardiac, renal, hepatic, neurologic and respiratory dysfunctions were recorded. Seven (5%) children developed AKI stage I, five children (4%) developed AKI stage II and two children developed AKI stage III (2%). All patients with AKI had a longer stay in hospital and increased mortality. Two children required dialysis for AKI and none developed chronic renal impairment. All patients with AKI stage III died during the ICU stay. Using stepwise regression, younger age (<1 year), weight <10 kg, pump failure, sepsis and duration of CPB >90 min were significant risk factors identified for developing AKI. AKI is common and occurred in 11% of our patients following CPB; however, AKI requiring renal replacement therapy is uncommon.

Vasoactive–inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass*

Inotrope score has been proposed as a marker of illness severity after pediatric cardiac surgery despite a lack of data to support its use as such. The goal of this study was to determine the association between inotropic/vasoactive support and clinical outcome in infants after cardiac surgery. Retrospective chart review. Dedicated pediatric cardiothoracic intensive care unit at an academic, tertiary care medical center. One hundred seventy-four patients 0 to 6 months of age admitted to the cardiothoracic intensive care unit after cardiac surgery with cardiopulmonary bypass between August 2007 and June 2008. Forty-three percent were neonates, and 39% had functional single ventricle physiology. None. Hourly doses of all vasoactive medications were recorded for the first 48 hrs after admission to the cardiothoracic intensive care unit and a vasoactive-inotropic score was calculated. The maximum vasoactive-inotropic score level over the first 48 hrs was a good predictor of poor clinical outcome (death, cardiac arrest, mechanical circulatory support, renal replacement therapy, and/or neurologic injury). After controlling for diagnosis, high maximum vasoactive-inotropic score was strongly associated with a poor outcome with an adjusted odds ratio of 8.1 (95% confidence interval, 3.4-19.2; p < .001) compared with patients with a low maximum vasoactive-inotropic score. High vasoactive-inotropic score was also associated with prolonged cardiothoracic intensive care unit stay, duration of mechanical ventilation, and time to negative fluid balance. The amount of cardiovascular support in the first 48 hrs after congenital heart surgery with cardiopulmonary bypass predicts eventual morbidity and mortality in young infants. The degree of support is best characterized by a maximum vasoactive-inotropic score obtained during this period. The usefulness of vasoactive-inotropic score as an independent predictor of clinical outcome in infants after cardiac surgery may have important implications for future cardiothoracic intensive care unit research.