RESUMEN
The purpose of the program WeCare was to provide a personalized approach to addressing the wide array of psycho-social-cultural-fiscal needs to reduce risk factors for infant mortality (IM) by supporting maternal and infant health through health coaching by community health workers (CHWs). A prospective cohort study of 1,513 women from highest risk ZIP codes for IM in central Indiana were followed over three years. The WeCare program focused on training and deploying CHWs to provide evidence-based, patient-centered social care and support to pregnant and postpartum women and tracked outcomes in health risk categories (mental health, nutrition, safe sleep, breastfeeding) targeted for behavioral change. The low birth weight rate among program participants was lower (8.9%) than Marion County's rate (10%) (p=0.23) with statistically significant improvement in many risk behaviors. Despite limitations, the personalized coaching provided by the CHWs provided an effective, practical approach to maternal and child health disparities.
Asunto(s)
Agentes Comunitarios de Salud , Mortalidad Infantil , Niño , Femenino , Humanos , Indiana/epidemiología , Lactante , Embarazo , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND/OBJECTIVES: There is controversy regarding the utilization of extracorporeal membrane oxygenation in pediatric patients with an underlying oncologic diagnosis or who have undergone hematopoietic cell transplant. We hypothesized that these patients have higher mortality, more bleeding complications, more blood product utilization, and a higher rate of new infections than the general pediatric intensive care unit population supported with extracorporeal membrane oxygenation. DESIGN/METHODS: This is a retrospective chart review at a single center quaternary care pediatric hospital including all pediatric intensive care unit extracorporeal membrane oxygenation patients from 2011 to 2016. Patients were categorized as either oncology/hematopoietic cell transplant or general pediatric intensive care unit. Patients from the cardiovascular intensive care unit or the neonatal intensive care unit were excluded. RESULTS: A total of 38 patients met inclusion criteria of which 7 were oncology/hematopoietic cell transplant patients. The oncology/hematopoietic cell transplant group had lower platelets at the start of extracorporeal membrane oxygenation (p = 0.02) but other pre-extracorporeal membrane oxygenation characteristics were similar. Extracorporeal membrane oxygenation survival was lower in the oncology/hematopoietic cell transplant group (29% vs 77%, p = 0.02). The incidence of bleeding complications and new infections did not differ. The oncology/hematopoietic cell transplant group received more platelets (median of 15.9 mL/kg/day (interquartile range 8.4, 36.6) vs 7.9 mL/kg/day (3.3, 21.9), p = 0.04) and fresh frozen plasma (14.0 mL/kg/day (3, 15.7) vs 1.8 mL/kg/day (0.5, 5.9), p = 0.04). CONCLUSION: Oncology and hematopoietic cell transplant patients had a higher mortality and received more blood products while on extracorporeal membrane oxygenation than the general pediatric intensive care unit patients despite similar pre-extracorporeal membrane oxygenation characteristics. Physicians should use caution when deciding whether or not to utilize extracorporeal membrane oxygenation in this population.
Asunto(s)
Oxigenación por Membrana Extracorpórea/métodos , Trasplante de Células Madre Hematopoyéticas/métodos , Acondicionamiento Pretrasplante/métodos , Preescolar , Femenino , Humanos , Masculino , Oncología Médica , Estudios RetrospectivosRESUMEN
BACKGROUND: Status asthmaticus is one of the most frequent admission diagnoses in the pediatric ICU (PICU). Collaboration between respiratory therapists (RTs) and physicians may help efficiently deliver care to a patient in status asthmaticus. The Pediatric Asthma Severity Score (PASS) is a measure of severity of a patient's asthma exacerbation at a point in time. The aim of this quality improvement initiative was to establish an RT-driven continuous albuterol weaning protocol using the PASS score. We hypothesized that this would decrease the duration of continuous albuterol without increasing adverse events. METHODS: This was a single-center implementation study in the PICU of a quaternary care children's hospital. Patients with a diagnosis of status asthmaticus who met criteria on continuous albuterol between September 2015 and September 2017 were included. An interdisciplinary team established the protocol, order sets, documentation, and education for involved staff. Qualifying subjects were assessed by an RT per protocol and assigned a PASS score, and the albuterol dose was adjusted on the basis of the PASS score. RESULTS: We compared 104 subjects studied before the implementation of this protocol (September 2015 to August 2016) to 117 subjects after the implementation of this protocol (September 2016 to October 2017). Median (interquartile range) duration of continuous albuterol in the PICU post-implementation was unchanged compared to pre-implementation: 12.1 (7.2-21.0) h versus 11.1 (6-19) h (P = .22). Median PICU length of stay was also unchanged post-implementation compared to pre-implementation: 19.5 (14.3-29.7) h versus 23.2 (15.2-31.3) h (P = .16). Using control charts, these processes were stable. There was no difference in adverse events. CONCLUSIONS: An interprofessionally-developed, RT-driven continuous albuterol weaning protocol can be implemented without negatively impacting duration of continuous albuterol or PICU length of stay and without increasing adverse events.
Asunto(s)
Albuterol , Terapia Respiratoria/métodos , Estado Asmático , Albuterol/administración & dosificación , Albuterol/efectos adversos , Broncodilatadores/administración & dosificación , Broncodilatadores/efectos adversos , Niño , Protocolos Clínicos , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos/prevención & control , Femenino , Humanos , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Grupo de Atención al Paciente , Estado Asmático/diagnóstico , Estado Asmático/terapia , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: The effectiveness of high-frequency oscillatory ventilation (HFOV) in the pediatric hematopoietic cell transplant patient has not been established. We sought to identify current practice patterns of HFOV, investigate parameters during HFOV and their association with mortality, and compare the use of HFOV to conventional mechanical ventilation in severe pediatric ARDS. METHODS: This is a retrospective analysis of a multi-center database of pediatric and young adult allogeneic hematopoietic cell transplant subjects requiring invasive mechanical ventilation for critical illness from 2009 through 2014. Twelve United States pediatric centers contributed data. Continuous variables were compared using a Wilcoxon rank-sum test or a Kruskal-Wallis analysis. For categorical variables, univariate analysis with logistic regression was performed. RESULTS: The database contains 222 patients, of which 85 subjects were managed with HFOV. Of this HFOV cohort, the overall pediatric ICU survival was 23.5% (n = 20). HFOV survivors were transitioned to HFOV at a lower oxygenation index than nonsurvivors (25.6, interquartile range 21.1-36.8, vs 37.2, interquartile range 26.5-52.2, P = .046). Survivors were transitioned to HFOV earlier in the course of mechanical ventilation, (day 0 vs day 2, P = .002). No subject survived who was transitioned to HFOV after 1 week of invasive mechanical ventilation. We compared subjects with severe pediatric ARDS treated only with conventional mechanical ventilation versus early HFOV (within 2 d of invasive mechanical ventilation) versus late HFOV. There was a trend toward difference in survival (conventional mechanical ventilation 24%, early HFOV 30%, and late HFOV 9%, P = .08). CONCLUSIONS: In this large database of pediatric allogeneic hematopoietic cell transplant subjects who had acute respiratory failure requiring invasive mechanical ventilation for critical illness with severe pediatric ARDS, early use of HFOV was associated with improved survival compared to late implementation of HFOV, and the subjects had outcomes similar to those treated only with conventional mechanical ventilation.