To determine whether implementation of an education-based intervention can sustainably improve upstream and downstream outcomes in intubated patients in a pediatric intensive care unit (PICU) in a ...low-resource country.
Quality improvement study comparing airway-related morbidity in two previously studied patient cohorts pre-intervention (Epoch 1) and immediately post-intervention (Epoch 2) with a third cohort thirty-six months post-intervention (Epoch 3).
PICU of the largest public children's hospital in El Salvador.
147 patients under 18 years requiring intubation and mechanical ventilation (MV) met inclusion criteria in the long-term follow-up period and were consecutively sampled without exclusion (Epoch 3) (compared to 98 previously studied patients in the short-term follow-up period (Epoch 2)).
A low-cost, education-based intervention to close knowledge gaps, improve communication among PICU doctors, nurses, and respiratory therapists, and optimize patient outcomes.
The primary outcome measure was change in unplanned extubation (UE) between Epochs 2 and 3. Other outcomes included use of cuffed endotracheal tubes (ETT), rate of elective ETT change and days of MV. The 17 % decrease in UE previously reported for Epoch 2 was sustained in Epoch 3. There was a statistically significant increase in use of cuffed ETT from 35.7 % in Epoch 2–55.1 % in Epoch 3 (p = 0.003, z-score −2.99). There was also a statistically significant mean difference in rate of elective ETT change per 100 MV days from Epoch 2 to Epoch 3 of 1.7 (p = 0.007; 95 % CI 0.15–0.84). There was no change in MV days from Epoch 2 to Epoch 3 (p-value 0.764; 95 % CI -1.48–2.02). Beyond these quantifiable results, many unanticipated practice changes were observed three years after the initial intervention.
Sustained improvement in upstream and downstream outcomes (UE, cuffed ETT use, elective ETT change) for intubated patients in a low-resource PICU were observed three years after a low-cost, low-touch, education-based intervention.
•Tracheal intubation is a high-risk procedure where quality improvement (QI) bundles have been linked to fewer adverse events.•Few studies have shown long-term favorable impact on patient care withQI bundles in low- and middle-income countries (LMIC).•This is the first study to show sustained outcomes improvement in intubated children in a LMIC after an educatioal bundle.•Such care improvement is critical for intubated children globally and, specifically, for those needing airway reconstruction.
This work describes a sustainable and replicable initiative to optimize multi-disciplinary care and uptake of clinical best practices for patients in a pediatric intensive care unit in Low/Middle ...Income Countries and to understand the various factors that may play a role in the reduction in child mortality seen after implementation of the Quality Improvement Initiative.BackgroundThis work describes a sustainable and replicable initiative to optimize multi-disciplinary care and uptake of clinical best practices for patients in a pediatric intensive care unit in Low/Middle Income Countries and to understand the various factors that may play a role in the reduction in child mortality seen after implementation of the Quality Improvement Initiative.This was a longitudinal assessment of a quality improvement program with the primary outcome of intubated pediatric patient mortality. The program was assessed 36 months following implementation of the quality improvement intervention using a t-test with linear regression to control for co-variates. An Impact Pathway model was developed to describe potential pathways for improvement, and context was added with an exploratory analysis of adoption of the intervention and locally initiated interventions.MethodsThis was a longitudinal assessment of a quality improvement program with the primary outcome of intubated pediatric patient mortality. The program was assessed 36 months following implementation of the quality improvement intervention using a t-test with linear regression to control for co-variates. An Impact Pathway model was developed to describe potential pathways for improvement, and context was added with an exploratory analysis of adoption of the intervention and locally initiated interventions.147 patients were included in the sustainability cohort. Comparing the initial post-implementation cohort to the sustainability cohort, the overall PICU unexpected extubations per 100 days mechanical ventilation decreased significantly from baseline (6.98) to the first year post intervention (3.52; p < 0.008) but plateaued without further significant decrease in the final cohort (3.0; p = 0.73), whereas the mortality decreased from 22.4 (std 0.42) to 9.5% (std 0.29): p value: 0.002 (confidence intervals: 0.05;0.21). The regression model that examined age, sex, diagnosis and severity of illness (via aggregate Pediatric Risk of Mortality (PRISM) scores between epochs) yielded an adjusted R-squared (adjusting for the number of predictors) value of 0.046, indicating that approximately 4.6% of the variance in mortality was explained by the predictors included in the model. The overall significance of the regression model was supported by an F-statistic of 3.198 (p = 0.00828). age, weight, diagnosis, and severity of illness. 15 new and locally driven quality practices were observed in the PICU compared to the initial post-implementation time period. The Impact Pathway model suggested multiple unique potential pathways connecting the improved patient outcomes with the intervention components.Results147 patients were included in the sustainability cohort. Comparing the initial post-implementation cohort to the sustainability cohort, the overall PICU unexpected extubations per 100 days mechanical ventilation decreased significantly from baseline (6.98) to the first year post intervention (3.52; p < 0.008) but plateaued without further significant decrease in the final cohort (3.0; p = 0.73), whereas the mortality decreased from 22.4 (std 0.42) to 9.5% (std 0.29): p value: 0.002 (confidence intervals: 0.05;0.21). The regression model that examined age, sex, diagnosis and severity of illness (via aggregate Pediatric Risk of Mortality (PRISM) scores between epochs) yielded an adjusted R-squared (adjusting for the number of predictors) value of 0.046, indicating that approximately 4.6% of the variance in mortality was explained by the predictors included in the model. The overall significance of the regression model was supported by an F-statistic of 3.198 (p = 0.00828). age, weight, diagnosis, and severity of illness. 15 new and locally driven quality practices were observed in the PICU compared to the initial post-implementation time period. The Impact Pathway model suggested multiple unique potential pathways connecting the improved patient outcomes with the intervention components.Sustained improvements were seen in the care of intubated pediatric patients. While some of this improvement may be attributable to the intervention, it appears likely that the change is multifactorial, as evidenced by a significant number of new quality improvement projects initiated by the local clinical team. Although currently limited by available data, the use of Driver Diagram and Impact Pathway models demonstrates several proposed causal pathways and holds potential for further elucidating the complex dynamics underlying such improvements.ConclusionSustained improvements were seen in the care of intubated pediatric patients. While some of this improvement may be attributable to the intervention, it appears likely that the change is multifactorial, as evidenced by a significant number of new quality improvement projects initiated by the local clinical team. Although currently limited by available data, the use of Driver Diagram and Impact Pathway models demonstrates several proposed causal pathways and holds potential for further elucidating the complex dynamics underlying such improvements.
Primary objective is to determine the rate of intubation with inappropriately sized endotracheal tubes (ETTs) in a pediatric intensive care unit (PICU) in El Salvador. Secondary objective is to ...determine effectiveness of a video-based curriculum to teach local providers on pediatric advanced airway management and surgical approach to patients requiring airway reconstruction.
Data for 296 intubated pediatric patients was collected over a six month period in a 16-bed PICU in El Salvador. Results of a learning behavior assessment survey completed by local healthcare workers informed a curriculum to complement on-site education during annual surgical airway mission trips. The video-based curriculum addressed proper sizing and use of cuffed endotracheal tubes, care of the intubated child and perioperative considerations of the surgical airway patient. Providers completed pre and post-curriculum quizzes to measure knowledge acquisition.
Over 6-months, 281 patients were intubated. Sixty-three percent had improperly sized ETTs. Thirty-one percent had a failed or accidental extubation. All-cause mortality was 24%. One hundred and fifty-nine Salvadorian providers completed a learning behavior survey informing a video-based curriculum. Sixty-four providers completed the curriculum. Post-curriculum quiz scores increased by 18.7%. Surgeons, anesthesiologist, intensivists and speech pathologists demonstrated significant improvement (p < 0.05).
Nearly two-thirds of intubated patients in a PICU in El Salvador have improperly sized ETTs and one-third require reintubation following planned or accidental extubation. The development of this first of its kind video-based curriculum for critical care and surgical training regarding how to properly care for the intubated child is coupled with the development of a longitudinal database to record pediatric airway related morbidity and mortality in the largest pediatric hospital in El Salvador. This model and system can be used to track the reduction in airway related morbidity and mortality directly related to a systems based intervention both in El Salvador and then elsewhere.
A large number of organizations that are committed to alleviating the suffering of those that are most in need. In an attempt to obtain data about medical missions, a recent research study yielded a ...list of 543 non-profit organizations. “Each of these organizations sends anywhere from 3 to 20 missions per year, for an annual total of approximately 6000 short-term missions sent to foreign countries from the United States.” This study was done by collecting statistics from the three largest mission websites – the International Healthcare Opportunities Clearinghouse, Diversion Magazine, and MissionFinder.org1 Though the previous figures demonstrate part of the statistics of medical missions, the data provided lacks the sociological factor. Numbers alone cannot provide a complete understanding of the success or failure of a project. Although both methods, qualitative and quantitative research, are important in their own, it is imperative to have access to both methods’ data in order to obtain a broader perspective of the subject in question. Each organization provides information of the patients that have been submitted for treatment, as well as statistical information such as budget spending. However, it is not an easy task to come across the stories behind the actual medical mission. These stories, for the most part, have been left untold. This thesis focuses on the stories of doctors, nurses, and volunteers who are or have been a part of medical missions around the world with the organization Doctors Without Borders. The purpose of this project is to provide a platform where humanitarian aid workers can share their personal experiences including their memories and feelings such as pain, laughter and fear. Focusing in qualitative research, I use the dynamic method of oral history.
This paper outlines the use of a global telehealth program to leverage the potential of telehealth to not only 1) preserve the previous progress of our pediatric surgical airway global teaching ...mission, but also: 2) to provide rapid, international dissemination of information related to care of pediatric COVID-19 patients; 3) to virtually support the attainment of self-sufficiency of our host countries in relation to our teaching mission; and 4) to inspire host countries to be local champions for each other during the COVID-19 crisis.
•Telemedicine conferences can sustain the progress of prior teaching mission trips.•Telehealth can help disseminate up-to-date information on COVID-19 patient care.•Host countries can be successfully virtually supported via telemedicine conferences.
To address whether a multidisciplinary team of pediatric otolaryngologists, anesthesiologists, pediatric intensivists, speech-language pathologists, and nurses can achieve safe and sustainable ...surgical outcomes in low-resourced settings when conducting a pediatric airway surgical teaching mission that features a program of progressive autonomy.
Consecutive case series with chart review.
This study reviews 14 consecutive missions from 2010 to 2019 in Ecuador, El Salvador, and the Dominican Republic.
Demographic data, diagnostic and operative details, and operative outcomes were collected. A country's program met graduation criteria if its multidisciplinary team developed the ability to autonomously manage the preoperative huddle, operating room discussion and setup, operative procedure, and postoperative multidisciplinary pediatric intensive care unit and floor care decision making. This was assessed by direct observation and assessment of surgical outcomes.
A total of 135 procedures were performed on 90 patients in Ecuador (n = 24), the Dominican Republic (n = 51), and El Salvador (n = 39). Five patients required transport to the United States to receive quaternary-level care. Thirty-six laryngotracheal reconstructions were completed: 6 single-stage, 12 one-and-a-half-stage, and 18 double-stage cases. We achieved a decannulation rate of 82%. Two programs (Ecuador and the Dominican Republic) met graduation criteria and have become self-sufficient. No mortalities were recorded.
This is the largest longitudinal description of an airway reconstruction teaching mission in low- and middle-income countries. Airway reconstruction can be safe and effective in low-resourced settings with a thoughtful multidisciplinary team led by local champions.
Unplanned extubation (UE) is orders of magnitude worse in low-income Pediatric Intensive Care Units (PICUs) than their high-income counterparts. Furthermore, a significant percent (20 %) of UEs ...result in a destabilizing event or cardiac collapse that negatively contributes to morbidity and mortality. As the principles of safe airway management are universal, we hypothesize that a multi-disciplinary educational intervention bundle which included provision of low-cost cuffed endotracheal tubes (ETT) and ETT tape will decrease the rate of unplanned extubation (UE) in a low-resourced PICU.
This is a pre-post interventional study powered to evaluate UE of intubated pediatric patients in an El Salvadorian PICU after a multi-disciplinary educational effort and provision of low-cost disposable materials. A multidisciplinary (otolaryngologists, intensivists, anesthesiologists, respiratory therapists, and nurses) educational curriculum involving hands on training, online video modules readily available via bedside QR codes, and pre- and post-testing was administered. The cost of the intervention materials was $1.32 per child. PICU mortality was evaluated as an exploratory outcome.
Nine-hundred and fifty-seven (859 pre-intervention and 98 post-intervention) patients met inclusion criteria. Patients with one or more UEs decreased significantly from 29.4 % to 17.3 % post-intervention (p = 0.01; CI: 0.28–0.88) with an odds ratio of 0.51. The use of a cuffed ETT increased from 12 % to 36 % (p < 0.001; CI: 0.17–0.44; OR:3.74) and cuffed ETT use was associated with a reduction in UE with an odds ratio of 0.40 (p < 0.001; CI: 0.24–0.66). Finally, there was a 4.3 % decrease in pediatric mortality from 26.7 % to 22.4 % that equates to a number needed to treat to prevent a single child mortality of 23. Therefore, the ICER per mortality prevented is $30.7 and the ICER per Disability Adjusted Life Year (DALY) is $0.44.
This multi-faceted intervention bundle is an accessible, scalable, cost-effective means to reduce UE and has implications in reducing global pediatric mortality.
•The rate of accidental extubation in low-resourced PICUs is very high (29.4 %).•A bundled intervention involving a multi-disciplinary education curriculum was created to address this issue.•This intervention reduced accidental extubation by nearly 50 %.•Pediatric ICU mortality was decreased by 4 %.•This educational-based intervention is a cost-effective means in a low-resourced setting.
Congenital nasal piriform aperture stenosis and choanal atresia are types of nasal obstructions that can be life threatening to infants if left untreated. While there has been numerous reports on ...both of them there has not been a single reported case of congenital nasal piriform aperture atresia. Here, we present the first case of piriform aperture atresia that includes the diagnostic and clinical approach.
PDF
