These posters have been presented at meetings in Children's Mercy and around the world. They represent research that was done at the time they were created, and may not represent medical knowledge or practice as it exists at the time viewers access these posters.>
Melissa Beals, Robert J. Krumsick, C. Clinton Frazee III, Lindsey J. Haldiman, and Uttam Garg
Oxcarbazepine is a derivative of carbamazepine that is used primarily in the treatment of epilepsy, and experimentally as a mood-stabilizer in adjunctive therapy for the treatment of bipolar disorder. Oxcarbazepine is converted through oxidation to its pharmacologically active metabolite 10-OH-Carbazepine, which is thought to be responsible for most of the anticonvulsant action of the drug. Adverse effects of oxcarbazepine are generally dose-dependent and may include fatigue, somnolence, dizziness, diplopia, nystagmus, and ataxia. Additive sedative effects have been noted when oxcarbazepine is used in combination with other CNS depressionproducing medications. Furthermore, oxcarbazepine and 10-OH-Carbazepine are powerful CYP2C19 inhibitors, potentially increasing the plasma concentration and pharmacological response of CYP2C19 substrates such as diazepam. The therapeutic range for oxcarbazepine is based on the metabolite and extends from 6-35 μg/mL. Toxicity has been reported with 10-OH-Carbazepine levels as low as 65 μg/mL, and one fatality has been documented with a 10-OH-Carbazepine concentration of 92 μg/mL. Hydrocodone is a narcotic analgesic that undergoes demethylation and reduction to produce several pharmacologically active metabolites, including hydromorphone, norhydrocodone, and dihydrocodeine (6-α-hydrocodol), which contribute to its efficacy. Hydrocodone toxicity may be characterized by respiratory depression, drowsiness, and coma. Therapeutic blood and plasma concentrations of hydrocodone typically range from 10-50 ng/mL, while levels greater than 100 ng/mL are considered toxic, and concentrations exceeding 200 ng/mL can be potentially fatal. Diazepam is a benzodiazepine known for its efficacy and rapid onset. Therapeutic ranges of diazepam and its metabolite nordiazepam in blood and plasma measure between 200-2500 ng/mL. Diazepam toxicity may result in drowsiness, weakness, ataxia, and coma; however, serious and fatal effects are uncommon with diazepam if used singularly. Most terminal adverse events associated with diazepam are the result of interaction or combination with other drugs, especially CNS depressants.
To present a case of a polysubstance related suicide involving the synergistic effect of toxic concentrations of oxcarbazepine and hydrocodone in combination with the presence of diazepam. To report the highest blood concentration of 10-OH-Carbazepine found in literature for a drug-related death investigation.
Presented in this case is a 67-year-old female with a history of depression, psychiatric hospitalization, and previous suicide attempts. The decedent was found lying supine in bed with a bottle of hydrocodone in one hand and a can of soda in the other, next to a suicide note. Several other prescription medications, including oxcarbazepine, gabapentin, diazepam, quetiapine, tizanidine, and lorazepam were found at the scene.
Postmortem heart blood, femoral blood, urine, vitreous fluid, gastric contents, and liver and brain tissue were submitted for toxicological analysis. Routine screening of heart blood was performed using Enzyme Multiplied Immunoassay Technique (EMIT) and liquid-liquid alkaline extraction followed by gas chromatography/mass spectrometry (GC/MS) analysis. 10-OH-Carbazepine as well as hydrocodone and its metabolites were quantified in femoral blood by an external laboratory using liquid chromatography/tandem mass spectrometry (LC-MS/MS). Diazepam and nordiazepam quantitation was performed on heart blood using high performance liquid chromatography (HPLC).
The most significant finding in this case is the 10-OH-Carbazepine concentration of 180 μg/mL, which is greater than the highest known fatal level of 92 μg/mL. The cause of death in this case was ruled oxcarbazepine and hydrocodone intoxication with diazepam use,
Alannah K. Yoder, Richard K. Ogden Jr., Ingrid A. Larson, and Emily J. Goodwin
Children with medical complexity require unique care, specialized attention, and a dedicated team to meet the needs of the patient & caregivers. Drug-therapy related problems in complex, chronic conditions influence financial, institutional, and patient outcomes. The addition of a pharmacist allows for collaboration and delivery of comprehensive medication management in order to provide value-added medication services to optimize complex therapeutic regimens and patient outcomes through evidence-based practice, medication adherence, medication use coordination, and medication safety processes.
Our program provides a pediatric medical home for hundreds of children with medical complexity. Families are cared for by a comprehensive medical team, including a clinical pharmacist. The pharmacist is available for all appointments and meets with patients and caregivers at the beginning of clinic visits. The pharmacist’s initiative to improve patient care is provided through multiple services which include: (1) comprehensive medication reconciliation through history provided by caregiver, outpatient pharmacy review, and chart review of specialty teams; (2) adverse drug assessment; (3) systemic drug-utilization review of each medication (drug-disease contraindication, drug-drug interaction, drug-patient precaution, dosing, duration of drug treatment, over and/or underutilization, drug dosage for modification, adherence concerns, and determination if additional monitoring is warranted); (4) patient education and development of personal, family-friendly medication lists; and (5) coordination of care between inpatient admissions, specialty/consulting services, home healthcare, and prior authorization needs.
The integration of a pharmacist in a pediatric medical home for children with medical complexity and childhood-onset disabilities allows for innovation and interdisciplinary collaboration to provide comprehensive medication management. Incorporation of family education and tangible medication plans promotes safe and consistent medication practices. Further studies describing the qualitative and quantitative impact on patient outcomes will be conducted at our institution.
Review of Karyotypic Data from Low Grade Glial Brain Tumors, Specifically Pilocytic Astrocytomas, and Correlation of Genetic Aberrations with Tumor Recurrence.
Linda D. Cooley, Scott C. Smith, Lisa Warren, Melissa Gener, Kevin Ginn, and John Herriges
Abstract: Brain tumors are the most common solid tumor of childhood. Approximately 50% of pediatric CNS tumors are low grade gliomas (WHO grade I or II) and Pilocytic astrocytoma (PA) is the most common accounting for 33% of all gliomas in children 0-14 years and ~18% of all childhood brain tumors. Prognosis with this slow-growing tumor is excellent; 10 year overall survival of ~95%. However, event free survival averages ~50%. Patient age and extent of tumor resection are key prognostic factors; tumor location and size impact resection and outcome. Histopathological features indicate PA is a benign tumor and rarely are anaplastic features of malignancy present. This study sought to determine if chromosomal aberrations correlate with increased risk of tumor recurrence. Observation shows that while the majority of PA have a normal karyotype, a portion have highly abnormal karyotypes; the clinical significance of which is unclear. Methods: Pathology archives were queried for PA between mid-2008 and mid- 2017. Review included chromosome, FISH, microarray, molecular results, cytogenetic methods, histopathology, tumor location, patient age, extent of surgical resection, chemotherapy, radiotherapy, and outcome. Karyotypes were defined as “aberrant” if there were multiple bizarre chromosome abnormalities, multiple telomeric association (tas) figures or translocations, or multiple dicentric chromosomes. Routine cell culture methods were used with mechanical +/- enzymatic disaggregation, alpha-MEM medium, and monolayer coverslip cultures with harvest as soon as feasible to capture metaphase cells. Results: Of 64 cultured PA, 4 failed to grow. Karyotypes were normal (n=32), simple (n=3), hyperdiploid (n=12), or aberrant (n=13). Four patients had a second tumor resection; 2 had aberrant and 2 had normal karyotypes on the initial and repeat studies. Of the 13 patient tumors with aberrant karyotypes, 6 tumors (CMH cases 1-5) demonstrated tas, dicentrics, subclones, etc., and two (CMH cases 6, 7) had multiple cells with an excess of aberrant chromosomes. Four tumors (CMH cases 8-13 – not shown) had a normal karyotype with one or two highly aberrant cells; of these, one patient with two resections (CMH cases 11 & 12) showed two highly aberrant cells on both the initial and second study. Discussion: Highly aberrant karyotypes are unexpected in benign tumors. PA, is a histologically benign tumor with ~95% 10 year overall survival. Repeatedly finding highly aberrant karyotypes in some of these tumors begs the question of clinical significance. How should these karyotypes be interpreted? Finding the abnormalities in tumors resected twice suggests an ongoing cellular/biologic process specific to that tumor tissue. The repeat finding of tas and dicentrics suggests a role for telomere dysfunction in these tumors. This is consistent with up-regulation of TRF1 and TRF2 (TTAGGG repeat-binding factors) occurring in the early stages of LGG carcinogenesis, which is characterized by short telomeres, genomic instability, low proliferative rate and prolonged life span (1). Limitations of the study: Data are limited – few patients, inconsistent FISH, microarray and molecular studies were done; no sequence analysis. Multiple factors play a role in patient outcome including tumor location and resectability. Conclusions: Additional cases, additional follow-up, additional genomic analyses are needed. Next step: WES of rearranged cases is planned.
Facilitating the everyday steward: Impact of mandatory antimicrobial indication/duration and a 48 hour time out
Ann L. Wirtz, Alaina N. Burns, Brian R. Lee, Tammy Frank, Laura Fitzmaurice, Richard Ogden, Brian O'Neal, and Jennifer Goldman
Introduction: Required indication, duration, and a 48-hour antimicrobial timeout are an integral part of antimicrobial stewardship standards; however, limited data are available to demonstrate an effect on antimicrobial utilization and antimicrobial stewardship practice. Therefore, we evaluated the impact of mandatory declared indication/duration along with a pharmacy-driven 48-hour timeout on antimicrobial utilization and antimicrobial stewardship interventions.
Methods: We performed a retrospective evaluation of ASP interventions and antimicrobial use following implementation of mandatory antimicrobial indication/duration at the point of computerized physician order entry (CPOE). A pharmacist-driven 48-hour antimicrobial timeout was introduced on the same date. This study was conducted at Children’s Mercy Kansas City, a 367-bed freestanding pediatric hospital servicing the Kansas City Metro Area and beyond. Data were collected from February 1, 2016 to January 31, 2018. A pre and post comparison was performed; interventions were implemented hospital-wide on February 14, 2017. ASP intervention rates were measured. Days of therapy (DOT) per 1000 patient days of antibiotics were also evaluated. Poisson models were utilized to compare DOT rates pre- and post-implementation, and seasonal decomposition analyses were performed to account for seasonal variability.
Results: A significant decrease in DOT rates was observed in non-ASP monitored antibiotics post-implementation, including cefazolin (39.7 to 36.9; p
Conclusions: Implementation of additional stewardship practices, including mandatory antimicrobial indication/ duration and a pharmacist-driven 48-hour timeout, resulted in a decrease in the use of antimicrobials, including those not monitored by our ASP. These efforts augmented, but did not replace existing stewardship efforts. These results support initiatives highlighted by national organizations to minimize unnecessary antimicrobial use through ASP.
Implementing Daily Management System Huddle Boards to Improve Communication Across Satellite Laboratories
In a laboratory setting with fast-paced changes and heavy demands on staff, day-to-day communication across departments is challenging, yet paramount to resource sharing and real-time problem solving. Children’s Mercy Hospital Kansas City (CMH) has implemented system-wide lean practices focused on clinical and operational excellence. Our laboratory mission, or True North, is to produce clinically relevant laboratory results and information to assist in the diagnosis, treatment and prognosis of patients in a timely manner, by: Reducing Errors – Pre-analytical, Analytical & Post-analytical Making encounters with the laboratory extraordinary Reducing turnaround times Maximizing employee engagement and productivity Reducing waste The first phase of the CMH Daily Management System (DMS) was to implement daily huddle and metrics boards. Each individual department would align unit-level readiness and quality metrics to the institution’s True North foundational elements and report on the following daily readiness objectives: 1. MESS: Methods, Equipment, Supplies, and Staffing (displayed as green or red) 2. Situation Awareness Notifications (abnormalities that need special attention that day) 3. Recognition (employees who go above and beyond contributions from previous day) 4. Announcements (department or institutional changes taking place that day) 5. Daily Workload (reported in patient volumes and previous day test volume) 6. Quick Hits and Big Issues (problem solving: QH completed within 3 days/check-in dates for each) A multi-tiered system would include huddle boards from individual department levels (i.e. Chemistry, Microbiology, or satellite department), one overall for the lab (pictured below), and the hospital as a whole. Each tier would report up to the next tier daily at the same time. Huddles are kept to five minutes or less.
DMS allows departments to identify MESS red/green thresholds that affect patient care. All information should be displayed in a simple, clear format where any employee walking by would understand how patient care is being delivered for that day. All huddle boards are dry erase for easy documentation and use red/green magnets to identify abnormalities “at a glance.” Huddles take place at the beginning of each shift with all stakeholders present to ensure clear communication between staffing changes. Departments are required to first determine what MESS levels would be considered abnormal (red). This requires breaking down testing platforms, staffing matrices and supply and inventory par volumes to ensure continual and efficient patient care. Any downtime, critical staffing level, or backorder that can cause delays in testing should be reported red for the day. Methods are department goals that are critical for care management and can be measured as they progress. This can include mandatory education for staffing or employee vaccination compliance. Problem solving is a daily occurrence. These issues are documented as “Quick Hits” (being completed within the department in three days or less) or “Big Issues” (taking additional time, resources, and possibly external departments). Each problem is assigned to a lead and given a due date to report back. Progress is reviewed during huddles and documented using Harvey Balls showing progress. These sheets can be used to show inspectors documentation of issues resolved in the department. Every department is required to identify situations that could cause delays in patient care. This can include, but is not limited to, IT downtime, courier delays, weather concerns, construction, or surges in patient volume. This information is followed up with Announcements and Employee Recognition. Metrics provide visual content to continual improvement. Metrics are also included in daily reporting, focusing on Safety, Employees, Quality, Delivery of Services, and Stewardship or Resources. These metrics must be measurable, contribute to improved patient care, employee engagement, operational and clinical excellence. These metrics should be department specific, timely, and patient centered.
Larger health systems often have satellite facilities in different geographical locations than the main hospital. Timely communication of department readiness across a health system is vital to ensure continual patient care when distance can affect distribution of additional resources. Telecommunications allows for huddles to take place online where information can be shared in real time. This allows for administration to allocate additional resources quickly, when necessary. CMH uses Polycom RealPresence to video conference huddles at the Tier 2 Laboratory Management huddle, as well as the hospital Tier 3 level. WebEx and Skype are other options for teleconferencing.
The Daily Management System has allowed for improved communication between shift exchange and departments throughout the hospital. The standardized process empowers frontline employees to identify abnormalities in staffing and equipment, resolution of issues, and efficiencies in process improvement. This bottom-up approach aligns with the True North mission allowing employees to become engaged and more solution-driven. Health systems with multiple satellite locations are able to connect via telecommunication technology, allowing for real-time reporting and deployment of resources. This ensures optimal utilization of resources that can be reallocated based on volume drivers within the department. Aligning department readiness and metrics with patient outcomes daily helps build a highly reliable organization focused on continuous improvement. In this continuously changing healthcare environment, institutions must become more efficient with limited resources, focused on clinical improvement, and empowering staff to discourage burnout. DMS is an effective lean tool for organizations wanting to break down silos, improve communication between departments, and strive towards clinical and operational excellence.
P16-Ki67-HMB45 Immunohistochemical Profiling May Help Discriminate Between Spitzoid Melanoma and Atypical Spitz Nevi
Robert E. Garola and Vivekanand Singh
When Spitz nevi have increased vertical thickness (>1.5 MM), show ulceration and deep seated mitosis, the differential diagnostic considerations of atypical Spitz nevus (ASN) or a Spitzoid melanoma (SM) enter into consideration. While expert consultation from a dermatopathologist is most often sought to resolve the differential diagnosis, it could be expensive and time consuming. Recently, the use of molecular genetic testing has also been advocated in the work group up of atypical melanocytic proliferations. On the contrary, immunohistochemistry is a more routinely used technique in most pathology centers may be more simple to apply. A single immunohistochemical marker may not be accurate enough to differentiate benign from malignant melanocytic lesions. Recently, one study (Ref. 1) employed the combination of p16, Ki-67 and HMB45 (PKH) immunohistochemistry on adult melanomas and proposed a combination of the three markers with scoring in discriminating SM and ASN in children. In this study we applied the methodology of the published study to atypical Spitzoid lesions and Spitzoid melanomas.
Methods •Institutional review board approval was obtained for this HIPAA-compliant study. •We retrospectively reviewed 10 cases (4 SM and 6 ASN) from children (age range 1.5-12 years, 6 females and 4 males). •H&E stained slides and immunohistochemical stains for PKH were independently interpreted by two pathologists. •The extent of IHC expression in the lesional cells were scored following published criteria comprised as follows:
-P16 scored as 0; >50% stained cells, 1; 11-50%, 2; 1-10%, 3; 0%
-Ki-67 scored as 0; <2%, 1; 2-5%, 2; 6-10%, 3; 11-20%, 4; >20%
-HMB45 scored as 0; gradient present, 1, doubtful/inconclusive gradient, 2; gradient absent
-The total PKH score for the combination of the 3 antibodies for any case could vary from 0 to 9.
Results • Four cases of SM had total PKH scores: 7, 6, 7 and 5. • Six cases of ASN had PKH scores of 3, 2, 3, 2, 3 and 3. •In our study all cases of SM had a total score of >4 and all ASN scored <4. • HMB45 was completely negative in one case each of SM and ASN. • Where aCGH was done, heterozygous loss of 9p correlated well with low P16 immunostain positive cell numbers in one case. Conclusions 1)Our study replicates the findings of the published study of adult melanomas and nevi that showed a total PKH score of equal/or>4 is seen in melanoma. 2) A single immunostain could be misleading as Ki-67 labeling index tended to be higher in young children (<2 years of>age) and HMB45 was occasionally negative in both ASN and SM, and P16 could be completely lost in ASN.
3) We suggest routine use of PKH immunohistochemistry in the work up of atypical Spitzoid lesions in children.
1) Uguen, A., et al. A p16-Ki-HMB45 immunohistochemistry scoring system as an ancillary diagnostic tool in the diagnosis of melanoma. Diag Pathol 2015; 10: 195-1005.
Jeremy Affolter, Kathlyn Baharaeen, Mari Hanson, Lisa Laddish, Amy Bohm, Lindsey Bradbury, Megan McGhee, Anne Leroy, Hannah Cunningham, Michelle Waddell, Tiffany Mullen, Kimberly Lucas, William Douglas, Angel Pope, Marita Thompson, Paul N. Bauer, Erica Molitor-Kirsch, Tara Benton, and Laura Miller-Smith
Rylee Ainge, Mackenzie Flaws, Natalie Heim, Emily Herndon, Hayley Norris, and Amy Scott
Kathlyn Baharaeen, Kimberly Palmer, Jamie Leroy, Julia Crouch, Bryan Limer, Gianna Swift, and Kate Gibbs
Tara Benton, Barb Haney, Lacey Bergerhofer, Susan Burns, Yolanda Ballam, and Kaitlyn Hoch
Tara Benton, Barb Haney, Lacey Bergerhofer, Susan Burns, Yolanda Ballam, and Kaitlyn Hoch
Haley Borchers, Kelly Fehlhafer, Barbara Mueller, Jessica Nichols, Sarah Talken, Mary Hunter, and Kenneth Sam
Shannon L. Carpenter, Laura Miller-Smith, Brittney Hunter, Ashley Duty, Justin Sheets, Yuri Tupa, and Kate Gibbs
Incredible Years (IY) Parents & Babies Well-Baby Program: Expanding the Reach through Cultural Adaptation
Ayanda Chakawa and Briana Woods-Jaeger
Ashley M. Cooper and Julia G. Harris
Sara Crawford, Stacy Pennington, Jeremy Affolter, Kathlyn Baharaeen, Paul N. Bauer, Tara Benton, Shekinah Hensley, Tiffany Mullen, and Michelle Waddell
Alicia Daggett and Brandi Missel
Sustainability and Outcomes of a Standardized Aminoglycoside Induced Ototoxicity Monitoring Algorithm
Claire Elson, Christopher M. Oermann, Michelle Weltman, and Ellen Meier
Reducing Discard Blood Draw Volumes from Subcutaneously Implanted Ports (PORT) in Patients with End Stage Renal Disease (ESRD)
Uttam Garg, Tyson Moore, Renita Trujillo, Penny Monachino, Amy Wiebold, Angela Ferguson, Gabor Oroszi, and Vimal Chadha
•To monitor clinical status, dialysis and transplant patients with ESRD frequently require blood draws.
•To preserve their veins and to avoid frequent intravenous access, these patients, especially young children, require PORT placement.
•The PORT is flushed with saline and filled with heparinized saline to prevent blood clotting between blood draws.
•To avoid contamination from PORT fluids, a fixed amount of blood is withdrawn and discarded before the blood sample is drawn for laboratory analyses. Currently, the recommended discard blood volume is 5 mL (five times the reservoir volume of most PORTs and attached catheters.)
•The volume of discarded blood can be significant, particularly in young patients with ESRD who are already anemic and who receive Epogen and iron therapy. This can be a leading cause of iatrogenic anemia.
•In this study, we evaluated the possibility of reducing the discarded blood volume from 5 mL to 3 mL without compromising laboratory results.
•To determine if a decrease in the discarded volume from 5 mL to 3 mL will still provide accurate and valid lab results for the two most commonly obtained clinical tests, complete blood count (CBC) and basic metabolic profile (BMP). Material and Methods
•Twelve patients with CKD who had a PORT placed as part of their clinical care were included in the study after obtaining informed consent. •Blood specimens for CBC and BMP were obtained for clinical indications only. •Fifty paired blood specimens were obtained between February and October 2017. •Blood specimens were obtained sequentially: study blood specimen (SmL) was obtained after a discard volume of 3 mL, followed by any additional blood draw equal to [5 - (3 + SmL)], followed by control blood specimen (C). •The chemistry (BMP) samples were analyzed on a Vitros® analyzer and hematology (CBC) samples were analyzed on a Sysmex® analyzer. •The agreement and variability between the results of the study (S) and the control (C) specimens were analyzed by regression analysis (coefficient of determination and line of equality), and Bland Altman analysis. •Variability limits for most analytes were set as one-third of the difference between the reference range for that particular analyte (red lines). •Statistical analysis was performed using MedCalc Statistical Software version 18.2.1, Ostend, Belgium.
•The coefficient of determination (R2) for all of the tested analytes was ³0.9 with the exception of bicarbonate (0.75); (p for all Conclusions
•The study specimen results showed a high degree of correlation (R2) on regression analysis and a slope approximating 1 (x = y) on the line of equality. •There was a very high degree of agreement between control and study specimen results on Bland Altman analysis. Only 6 (1%) of the results were outside the preset clinically acceptable limits. •Our results suggest that for at least CBC and BMP, the discard blood volume can be safely decreased from 5 to 3 mL, a 40% decrease in blood wastage without impacting the validity and accuracy of the results.
Significant Loss of Blood Amino Acids and Free Carnitine in Newborns Receiving Continuous Renal Replacement Therapy (CRRT)
Uttam Garg, Marita Thompson, Bradley A. Warady, and Vimal Chadha
•Newborns with acute kidney injury (AKI) or end-stage kidney disease (ESKD) often receive prolonged CRRT when the early initiation of peritoneal dialysis is either contraindicated or unable to be performed. •These patients often receive total parenteral nutrition (TPN) to meet their nutritional goals. •Little to no information exists on the loss of blood amino acids (AA) and carnitine during CRRT in these patients. •The objective of this study was to determine the amino acids and carnitine losses in newborns receiving prolonged CRRT and TPN. Material and Methods
•Three newborns who received prolonged (> 2 weeks) CRRT and TPN were included in the study. Blood and CRRT effluent were simultaneously collected from these patients. •The effluent specimens were collected over 8-12 hours and the results were extrapolated to 24 hrs. Plasma was separated from blood for the analysis of 30 amino acids and free carnitine. •Amino acids in plasma and CRRT effluent were analyzed using an amino acid analyzer which uses ion-exchange chromatography and post-column ninhydrin derivatization (Biochrom System). Free carnitine was determined by HPLC-tandem mass spectrometry (HPLC-MS/MS) using flow injection, electrospray ionization and precursor ion scan. •The total amount of amino acids and carnitine received by each patient was calculated from the amino acids concentrate and carnitine added to the TPN solution. •The sieving coefficients (SQ) for each measured amino acid and carnitine was determined, while the amino acids and carnitine losses were calculated as mg/day, and as a percentage of the intake. Results •The blood flow was 50 mL/min for all three cases, and the CVVHDF clearance ranged from 68 – 115 mL/kg/hr (1.4 – 3.2 L/hr/1.73 m2). •The AA intake varied from 3.8 – 4.5 gm/kg/day. Carnitine intake was 20 mg/kg/day in two patients and 50 mg/kg/day in the third. •The SQ for all essential AAs was >0.8; in contrast, acidic AAs (glutamic and aspartic acid) had a SQ 0.84 and carnitine losses were 80% of the daily intake. •At the given high protein intake, all three patients achieved a positive N2 balance ranging from 0.45 to 0.59 gm/day.
•During CRRT, most of the AAs (including all essential AAs) are freely filtered and the quantity lost is influenced by the CRRT clearance. •In our very small sample of patients, positive nitrogen balance was achieved in all three patients with a very high (3.8 – 4.5 gm/kg/day) protein intake. •As carnitine is rapidly and freely filtered during CRRT, these patients are at risk of significant carnitine depletion. •The impact of serum AA and carnitine losses on nutritional outcome in patients with renal disease receiving CRRT is not known at this time. •Additional studies are needed to determine if these patients require special AA formulations and the degree of carnitine supplementation in their TPN to account for the AA and carnitine losses that regularly occur.
Kristi Gordon, Elizabeth Simpson, Sarah Forge, and Eileen Almon
•In 2012, our hospital expanded obstetrical services resulting in the delivery over 3700 infants per year.
•Approximately 35% of these infants had no relationship to a primary care physician with privileges at our hospital.
•These infants were either uninsured, Medicaid insured or privately insured but whose primary care physician did not have hospital privileges.
•Private Pediatricians “on call” were given these unassigned infants and were attempting to evaluate infants in the mornings, prior to seeing their scheduled office patients
•This resulted in an unmanageable daily census for them.
•This led to Pediatrician dissatisfaction, delayed medical evaluations of some infants, discharge planning dilemmas and financial burdens to both the hospital and the Pediatricians on staff.
•The existing affiliation with an Academic Children’s Hospital for Neonatology Professional and Neonatal Intensive Care Directorship services was expanded to include an Advanced Practice Registered Nurse (APRN) Newborn Hospitalist service to care for unassigned, routine newborns. Oversight was provided by physicians within the Division of Neonatology dedicated to coverage for this service.
Newborn Hospitalist Role
•Provide care to infants born at the delivery center whose primary care providers are not on staff.
•Dedicate 100% professional effort on newborns outside of intensive care setting. •Recent QI projects:
•Improving testing for drugs of abuse.
•Implementation of transcutaneous monitoring of bilirubin.
•Refining car seat testing guidelines.
•The team is currently preparing the first edition of a newsletter, Newborn Connections.
•Consistent, timely medical evaluation of all infants without consideration of insurance/Physician availability or limitations.
•Safe, comprehensive, quality care for all infants without need for Private Pediatrician oversight.
•High family satisfaction ratings on patient satisfaction survey. •Small number of dedicated APRN Providers led to standardized education and care for families. •Consistent availability of services improved communication with nursing staff and hospital administrative staff.
•Improved discharge coordination with scheduled PCP follow-up appointments prior to hospital discharge.
•Affiliation with local Academic Center/Neonatology, improved credibility with families and seamless transition between NICU and routine newborn services. •APRN job satisfaction/career growth opportunities with autonomy building hospitalist service and coordination with supervisory physicians
•In our state, development and growth of an APRN -led Newborn Hospitalist Service has permitted a population of infants to receive consistent, safe, quality care.
•This program could be duplicated at institutions with similar circumstances
Medication Timeliness in Emergency Department in Pediatric Sickle Cell Disease Population Presenting with Vaso-Occlusive Episode
Derrick Goubeaux, Kaitlyn Hoch, Gerald Woods, Julie Routhieaux, Maureen Guignon, and Valerie McDougall Kestner
Luke A. Harris and Douglas Blowey
Leslie Hueschen, Stephanie Burrus, Andrea Raymond, Charity Thompson, Lisa Carney, and Jay Rilinger
Early recognition of sepsis and designing a huddle process are key drivers of the Improving Pediatric Sepsis Outcomes (IPSO) collaborative. Our tertiary care, free-standing, pediatric hospital joined the IPSO collaboration in 2016. Our hospital began piloting Situation Awareness (SA) Escalation Huddles in 2016, to improve recognition of patients with clinical deterioration. The tool triggers if a patient has a high PEWS(> 5), requires initiation of hi-flow nasal cannula, or for staff/parental concern. The SA paper tool guides the communication process and steps of the huddle. Huddles include a nurse, provider, and respiratory therapist. One of the goals of the SA escalation huddle is to decrease the amount of Advanced Life Support code blue events and rapidly identify sepsis patients on the inpatient units. Prior to this study there was no formal screening process for sepsis in the inpatient units.
•Identify septic patients early on inpatient units by forcing consideration of sepsis during SA screening in high-risk patients. •Utilize existing SA screening tool without employing increased work demands on care providers. •Ultimately, improve timely treatment of septic patients (antibiotics, fluid resuscitation) and escalate to higher level of care earlier, if indicated.
In Fall 2017, a question “Sepsis Concern?” was added to the SA tool to better identify septic patients. Roll out of new SA tool was completed in a step-wise process throughout the hospital and completed January 2018 in all units. We collected the number of PICU transfers with + SA tool. We hypothesized this change should lead to timely identification of sepsis, care team huddle with bedside discussion, treatment, and escalation of care. Sepsis clinical practice guidelines and order-sets were developed in conjunction to aid in the decision making process.
There were 162 number of severe sepsis patients treated from September 2017 to March 2018 in our hospital. There were an average of 23 severe sepsis patients each month. 21% (34/162) of these patients were identified to have possible sepsis on the inpatient units.
From September 2017 to March 2018, 1,012 SA tools were triggered with a mean of 4.8 huddles/day. The average patient had an average 2.3 (1,012/445) SA huddles during their hospitalization. Of SA triggers, 49 huddles (over 34 patients) screened positive for “Sepsis Concern?”(4.8%,49/1,012). 71% of “+ Sepsis Concern” episodes were treated as possible severe sepsis (35/49). Of the “+ sepsis concern” patients, 29% (10/34) were transferred to the ICU. When completing the SA form 13.3% (135/1,012) skipped the “Sepsis Concern?” question.
During the study, 21% of PICU transfers for possible severe sepsis had the SA tool used (3/14) prior to transfer.
The majority of sepsis patients identified with the SA tool had severe sepsis and required ICU care. Ideally the “concern for sepsis” question would generate a shared mental model in the diagnosis and treatment of sepsis, however even questioning the possibility of sepsis and discussion about sepsis remains challenging.
David G. Ingram MD, Gaylyn Perry MD, Zarmina Ehsan MD, and Baha Al-Shawwa MD
•Iron status is an important aspect of the evaluation of children with excessive limb movements during sleep. •While there is clear data in adults to support this relationship, the data in children is less well established. •We evaluated the association between iron status and limb movements during sleep in a large pediatric sample. Methods •This is a retrospective analysis of a single institution sleep program looking at all patients who underwent overnight polysomnogram and ferritin test within 24 hours of doing the sleep study between January 2015 and October 2017. •Those with sleep apnea (Central Apnea Index >5/hr or Obstructive Apnea Hypopnea Index >2/hr) were excluded. Results •There were a total of 418 patients who qualified for inclusion. Mean age was 5.6 years (range 0–19 years). •Overall, higher ferritin level was significantly associated with increasing age, increasing N2 sleep, lower REM sleep and lower single limb movement index but did not correlate with periodic limb movements of sleep. •It appears that ferritin level at 30 nanograms per milliliter is the cutoff to make a difference in improving single limb movements (7.2+/-2.7 vs 7.9 +/- 3.6 for above and below 30 ng/ml, respectively). •In multivariate regression modelling including single limb movement index and age, the association between ferritin and limb movements was no longer significant. Conclusions •Overall, there is a weak correlation between ferritin and single limb movements during sleep. •However, it appears that age is an important possible confounding factor in the complex relationship between and iron status and limb movements in children.