SO016SPREAD OF ACUTE KIDNEY INJURY IMPROVEMENT PROGAMME ACROSS A LARGE  MULTI SITED NHS HOSPITAL

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Prasanna Hanumapura ◽  
Leonard Ebah ◽  
Deryn Waring ◽  
Robert Henney ◽  
Michelle Murphy ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Change Agent ◽  
Kidney Injury ◽  
Care Process ◽  
Multidisciplinary Teams ◽  
Successful Implementation ◽  
Care Organization ◽  
Children's Hospital ◽  
Children’S Hospital ◽  
Incident Cases

Abstract Background and Aims Acute kidney injury (AKI) is a widely recognised serious health care issue. Up to 25% of hospital patients can develop it, with worse outcomes compared non AKI. A UK–wide audit in 2009 and our local audit in 2014 showed consistently poor AKI care including delays in detection and inconsistent management of cases. The trust set up the AKI Team in 2014 to improve AKI detection, care and outcomes. Successful implementation of a Multifaceted Quality Improvement (QI) Programme for AKI across the main hospital campus since 2015 saw significant improvement in AKI care and outcomes; recognition within 24hrs improved from 52% to 100% since 2016; there has been a 34% reduction in AKI incidence, 26% reduction in AKI length of stay (LoS) ,42% reduction in AKI days (time to recovery) and 10% less AKI associated mortality. The Trust being one of the largest acute trusts in the UK (10 hospitals across 6 sites, over 2000 beds), the QI spread represented a formidable challenge. We describe the methodology and outcomes of AKI QI spread across the trust. Method Central Campus Hospitals Improvement on this site involved setting a bespoke electronic alert coupled with education, key stake holder engagement, gradual culture change and AKI Priority Care Checklist (PCC) and use of change agent (AKI Clinical Nurse Specialist-CNS) visiting local teams and empowering them to manage AKI using Demming’s Model for Improvement A stepwise staggered similar approach was implemented first in the Women’s and Eye Hospitals followed by Children’s Hospital after a local adaptation and testing of algorithm, PCC and appointment of local change agent, a Paediatric AKI CNS. West Campus Hospital A DGH with 230 beds, 1-2 incident cases of AKI/day required a bespoke approach. The central AKI team runs an AKI alerts report and remotely alert the local multidisciplinary teams and empowering them to implement the PCC. South Campus Hospitals A large tertiary hospital merged in 2018 with an existing AKI CNS team. Detection algorithms, education material, PCC, reporting, and approach have been progressively harmonized using the Central Campus model. Data is expressed using SPC charts and analysed by t-test. Results Care process and outcome measures have seen a consistent improvement across all sites. As reported in the Central Campus, recognition of AKI within 24hrs has improved from 52% to 100% since 2016; there has been a 34% reduction in AKI incidence (p<0.00001), 26% reduction in AKI LoS and a 42% reduction in AKI days (time to recovery). The Children’s Hospital had 24% reduction (p<0.0001) in AKI incidence and a 34% reduction in hospital acquired AKI. Recognition of AKI has improved from 42% to 100%; 15% reduction in AKI LoS and 22% reduction in AKI days. In the South Campus recognition of AKI has improved from 67% to 100% and 19% reduction (p<0.0015) in AKI incidence. LoS and AKI days data yet to be reported whilst IT systems are been harmonised. In West Campus recognition is 100% but the small numbers prevent any meaningful analysis of other outcomes. Conclusion This study demonstrates how a cluster of simple interventions and approach to AKI detection and care were successfully rolled out across a multisite large complex acute care organization taking into account the local realities of each site/Hospitals whilst maintaining the core interventions.

scholarly journals Acute Kidney Injury in COVID-19-associated Multisystem Inflammatory Syndrome in Children (MIS-C)

Kidney360 ◽  
2021 ◽  
pp. 10.34067/KID.0005372020
Author(s):  
Marissa Lipton ◽  
Ruchi Gupta Mahajan ◽  
Catherine Kavanagh ◽  
Carol Liu Shen ◽  
Ibrahim Batal ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Renal Injury ◽  
Left Ventricular Systolic Dysfunction ◽  
Systolic Dysfunction ◽  
Kidney Injury ◽  
Left Ventricular ◽  
Ventricular Systolic Dysfunction ◽  
Children's Hospital ◽  
Children’S Hospital ◽  
Inflammatory Syndrome

Background: Multisystem Inflammatory Syndrome in Children (MIS-C) is a recently identified entity in association with COVID-19. Acute kidney injury (AKI) has been widely reported in patients with primary COVID-19 infection. However, there is a paucity of literature regarding renal injury in MIS-C. We aim to characterize AKI in MIS-C in this cohort identified at a major children's hospital in New York City during the COVID-19 pandemic. Methods: We conducted a retrospective cohort study of children 0-20 years old admitted to Morgan Stanley Children's Hospital (MSCH) between April 18th and September 23rd, 2020. Patients were included if they met criteria for MIS-C based on CDC guidelines. All patients were evaluated for the presence of AKI, and AKI was staged according to KDIGO criteria. Results: Of the 57 children who met inclusion criteria, 46% (26/57) were found to have AKI. The majority of patients, 58% (15/26), were classified as KDIGO Stage 1. AKI was present upon admission in 70% of those identified. All patients had resolution of AKI at discharge, with 61% achieving recovery by day 2. One patient required dialysis. When compared to those without renal injury, the AKI cohort was older (p < 0.001) and with higher median peak values of CRP (p <0.001), IL-6 (p <0.05), ferritin (p < 0.001), and procalcitonin (p <0.05). More patients with AKI had left ventricular systolic dysfunction (p < 0.001) and lymphopenia (p <0.01), when compared to those without AKI. No differences in Body Mass Index or sex were found. Conclusion: While children with MIS-C may develop AKI, our study suggests most experience mild disease, swift resolution, and promising outcome. Older age, increased inflammation, and left ventricular systolic dysfunction may be risk factors. Our study highlights the substantial differences in epidemiology and outcomes between AKI associated with pediatric MIS-C versus primary COVID-19 infection.

An Outbreak of Methicillin-Resistant Staphylococcus aureus in a Neonatal Intensive Care Unit

2003 ◽  
Vol 24 (5) ◽  
pp. 317-321 ◽  
Author(s):  
Lisa Saiman ◽  
Alicia Cronquist ◽  
Fann Wu ◽  
Juyan Zhou ◽  
David Rubenstein ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Staphylococcus Aureus ◽  
Intensive Care ◽  
Neonatal Intensive Care Unit ◽  
Neonatal Intensive Care ◽  
Methicillin Resistant ◽  
Children's Hospital ◽  
Surveillance Cultures ◽  
Children’S Hospital ◽  
Incident Cases

AbstractObjective:To describe the epidemiologic and molecular investigations that successfully contained an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in a neonatal intensive care unit (NICU).Design:Isolates of MRSA were typed by pulsed-field gel electrophoresis (PFGE) and S. aureus protein A (spa).Setting:A level III-IV, 45-bed NICU located in a children's hospital within a medical center.Patients:Incident cases had MRSA isolated from clinical cultures (eg, blood) or surveillance cultures (ie, anterior nares).Interventions:Infected and colonized infants were placed on contact precautions, cohorted, and treated with mupirocin. Surveillance cultures were performed for healthcare workers (HCWs). Colonized HCWs were treated with topical mupirocin and hexachlorophene showers.Results:From January to March 2001, the outbreak strain of MRSA PFGE clone B, was harbored by 13 infants. Three (1.3%) of 235 HCWs were colonized with MRSA. Two HCWs, who rotated between the adult and the pediatric facility, harbored clone C. One HCW, who exclusively worked in the children's hospital, was colonized with clone B. From January 1999 to November 2000, 22 patients hospitalized in the adult facility were infected or colonized with clone B. Spa typing and PFGE yielded concordant results. PFGE clone B was identified as spa type 16, associated with outbreaks in Brazil and Hungary.Conclusions:A possible route of MRSA transmission was elucidated by molecular typing. MRSA appears to have been transferred from our adult facility to our pediatric facility by a rotating HCW. Spa typing allowed comparison of our institution's MRSA strains with previously characterized outbreak clones.

A clinical case of hamartoma (teratoma) of the tongue in combination with a cleft palate in a newborn

2020 ◽  
pp. 42-45
Author(s):  
Yu.O. Volkov ◽  
Ad.A. Mamedov ◽  
L.M. Makarova ◽  
E.A. Ryzhov ◽  
B.A. Tkachenko
Keyword(s):  
Cleft Palate ◽  
Congenital Malformation ◽  
Clinical Case ◽  
Interdisciplinary Approach ◽  
Successful Implementation ◽  
Maxillofacial Region ◽  
Children's Hospital ◽  
Children’S Hospital ◽  
Newborn Child ◽  
Subsequent Rehabilitation

The article presents a rare clinical case of hamartoma of the tongue in combination with a cleft palate, diagnosed in a newborn child, as a manifestation of a severe congenital malformation of the maxillofacial region. The preparation and successful implementation of the first stage of treatment of this combined pathology and subsequent rehabilitation in a multidisciplinary children's hospital are described in detail on the basis of continuity in the work of specialists and an interdisciplinary approach.

scholarly journals Acute kidney injury electronic alerts: mixed methods Normalisation Process Theory evaluation of their implementation into secondary care in England

BMJ Open ◽  
2019 ◽  
Vol 9 (12) ◽  
pp. e032925
Author(s):  
Jason Scott ◽  
Tracy Finch ◽  
Mark Bevan ◽  
Gregory Maniatopoulos ◽  
Chris Gibbins ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
Mixed Methods ◽  
Secondary Care ◽  
Qualitative Data ◽  
Kidney Injury ◽  
Process Theory ◽  
Normalisation Process Theory ◽  
Successful Implementation ◽  
Structured Interviews ◽  
Electronic Alerts

ObjectiveAround one in five emergency hospital admissions are affected by acute kidney injury (AKI). To address poor quality of care in relation to AKI, electronic alerts (e-alerts) are mandated across primary and secondary care in England and Wales. Evidence of the benefit of AKI e-alerts remains conflicting, with at least some uncertainty explained by poor or unclear implementation. The objective of this study was to identify factors relating to implementation, using Normalisation Process Theory (NPT), which promote or inhibit use of AKI e-alerts in secondary care.DesignMixed methods combining qualitative (observations, semi-structured interviews) and quantitative (survey) methods.Setting and participantsThree secondary care hospitals in North East England, representing two distinct AKI e-alerting systems. Observations (>44 hours) were conducted in Emergency Assessment Units (EAUs). Semi-structured interviews were conducted with clinicians (n=29) from EAUs, vascular or general surgery or care of the elderly. Qualitative data were supplemented by Normalization MeAsure Development (NoMAD) surveys (n=101).AnalysisQualitative data were analysed using the NPT framework, with quantitative data analysed descriptively and using χ2 and Wilcoxon signed-rank test for differences in current and future normalisation.ResultsParticipants reported familiarity with the AKI e-alerts but that the e-alerts would become more normalised in the future (p<0.001). No single NPT mechanism led to current (un)successful implementation of the e-alerts, but analysis of the underlying subconstructs identified several mechanisms indicative of successful normalisation (internalisation, legitimation) or unsuccessful normalisation (initiation, differentiation, skill set workability, systematisation).ConclusionsClinicians recognised the value and importance of AKI e-alerts in their practice, although this was not sufficient for the e-alerts to be routinely engaged with by clinicians. To further normalise the use of AKI e-alerts, there is a need for tailored training on use of the e-alerts and routine feedback to clinicians on the impact that e-alerts have on patient outcomes.

scholarly journals Reducing Acute Kidney Injury Due to Contrast Material: How Nurses Can Improve Patient Safety

2017 ◽  
Vol 37 (1) ◽  
pp. 13-26 ◽  
Author(s):  
Peggy Lambert ◽  
Kristine Chaisson ◽  
Susan Horton ◽  
Carmen Petrin ◽  
Emily Marshall ◽  
...  
Keyword(s):  
Acute Kidney Injury ◽  
New England ◽  
Interventional Procedures ◽  
Task Force ◽  
Improve Patient Safety ◽  
Contrast Material ◽  
Kidney Injury ◽  
The United States ◽  
Multidisciplinary Teams ◽  
Oral Hydration

BACKGROUND Acute kidney injury due to contrast material occurs in 3% to 15% of the 2 million cardiac catheterizations done in the United States each year. OBJECTIVE To reduce acute kidney injury due to contrast material after cardiovascular interventional procedures. METHODS Nurse leaders in the Northern New England Cardiovascular Disease Study Group, a 10-center quality improvement consortium in Maine, New Hampshire, and Vermont, formed a nursing task force to reduce acute kidney injury due to contrast material after cardiovascular interventional procedures. Data were prospectively collected January 1, 2007, through June 30, 2012, on consecutive nonemergent patients (n = 20 147) undergoing percutaneous coronary interventions. RESULTS Compared with baseline rates, adjusted rates of acute kidney injury among the 10 centers were significantly reduced by 21% and by 28% in patients with baseline estimated glomerular filtration rate less than 60 mL/min per 1.73 m2. Key qualitative system factors associated with improvement included use of multidisciplinary teams, standardized fluid orders, use of an intravenous fluid bolus, patient education about oral hydration, and limiting the volume of contrast material. CONCLUSIONS Standardization of evidence-based best practices in nursing care may reduce the incidence of acute kidney injury due to contrast material.

scholarly journals Creation and Validation of a Pediatric Vancomycin Nomogram for a Goal Trough of 10–15 mg/L at a Quaternary Care Children’s Hospital

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S300-S300 ◽  
Author(s):  
Philip Lee ◽  
Jessica Frye ◽  
Xing Chen ◽  
Susanna Chang ◽  
Birender Singh ◽  
...  
Keyword(s):  
Kidney Injury ◽  
Target Range ◽  
Older Children ◽  
Children's Hospital ◽  
Starting Dose ◽  
Children’S Hospital ◽  
Mrsa Infection ◽  
The Mean ◽  
Serum Vancomycin ◽  
Schwartz Equation

Abstract Background Recent data suggest a serum vancomycin (vanc) trough (VT) of 11mg/L correlates with an AUC/MIC24 &gt; 400 which has shown to be the optimal concentration to eradicate MRSA infection and improve mortality. There are currently limited published recommendations on how to achieve such a VT in children. This study validates a vancomycin nomogram used to achieve a VT of 10–15 mg/L in pediatric inpatients (pts) at a quaternary care children’s hospital. Methods This is an 18 month (mo) prospective analysis beginning in September 2015. Included pts were ≥2 mo of age and had ≥2 consecutive VT. Pts receiving renal replacement therapy or those with a serum creatinine (Scr) of ≥0.5 mg/dL from a prior admission or within 48 hours of vanc initiation were excluded. The starting dose (SD) of vanc was determined by age and creatinine clearance (CrCl) (Tables 1 and 2). CrCl was measured by Bedside Schwartz equation for patients ≤18 years old (yo) and Cockcroft-Gault equation for patients &gt;18 yo. The maximum CrCl was set to 120 ml/minute. Patients who were on vanc and experienced a Scr increase of ≥0.5 mg/dL were considered to have acute kidney injury (AKI). The study had a 6 mo evaluation period which led to a revised version (RVN) on March 2016. The primary endpoint (PE) was achievement of 10–15 mg/L by the Second VT for patients with the First trough outside of this range, using our RVN (Table 3). Results Overall, a total of 276 patients received vanc, 17 and 29 patients were dosed according to the initial and RVN, respectively. For young children (Table 1), the SD for patients with a CrCL ≥90 ml/minute was therapeutic, sub-, and supra-therapeutic in 43.75%, 47.5% and 8.75%, respectively. For older children (Table 2), the SD for patients with a CrCl ≥100 ml/minute was therapeutic, sub-, and supra-therapeutic in 41.1%, 35.7% and 23.2%, respectively. The initial VN was successful 12/17 (70.6%) in achieving the PE. Success in achieving the PE after the RVN was 26/29 (89.7%). In the RVN group, the most common initial troughs were 5–7 mg/L (33.3%), followed by &gt;18 mg/L (27.6%). The mean VT using the RVN was 13.7 mg/L. The overall AKI incidence throughout the study was 3.2% (9/276) and 0% using the RVN. Conclusion Our RVN led to a Second VT within a target range of 10–15 mg/L for 89.7% of patients, allowing for more accurate and safer use of vancomycin in our institution. Disclosures All authors: No reported disclosures.

scholarly journals Comparing Vancomycin Area Under the Curve With a Pharmacist Protocol that Incorporates Trough and Maximum Doses at a Children's Hospital

2021 ◽  
Vol 26 (7) ◽  
pp. 740-745
Author(s):  
Betool O. Al-Mazraawy ◽  
Jennifer E. Girotto
Keyword(s):  
Area Under The Curve ◽  
Kidney Injury ◽  
Population Data ◽  
Patient Specific ◽  
Prospective Data ◽  
Children's Hospital ◽  
Dose Modification ◽  
Hospital Patients ◽  
Children’S Hospital ◽  
Secondary Analyses

OBJECTIVE Updated vancomycin guidelines suggest dose adjustment based on area under the curve in a 24-hour period (AUC24). This study aims to determine whether a pharmacist managed vancomycin protocol that incorporates maximum dosing paired with trough monitoring can achieve appropriate vancomycin AUC24 exposures. METHODS A retrospective review was performed evaluating vancomycin usage from October 2018 through September 2019 at a children's hospital. Patients with less than 4 doses or lack a trough concentration were excluded. Vancomycin AUC24 were estimated using 2 calculations: 1) the Le method, incorporating age and serum creatinine, and 2) the trapezoidal method based upon population data and patient-specific trough. Target AUC24 ranges were assessed. AUC24 goals were 400 to 600 mg·hr/L, but due to known variations between calculations, a variance of 20 mg·hr/L was allowed for each end of the goal. Secondary analyses included evaluations of efficacy and toxicity. RESULTS Two-hundred twenty-three patients were included. Initial doses were estimated to meet AUC24 goals in only 63%. After trough-based dose modification, 81% achieved a therapeutic AUC24. Using the trapezoidal method, therapeutic concentrations were found in 51% of patients based on the initial dose and 77% after dose modification. Only 6.3% of patients had kidney injury with only 1 of those patients having any calculated AUC24 &gt; 600 mg·hr/L and none above 620 mg·hr/L. No clinical failures were identified. CONCLUSIONS Increased initial dosing in infants and children is needed to result in AUC24 exposures recommended in the guidelines. Maximum dosing paired with trough monitoring may be an alternative to AUC24 monitoring in areas that are unable to perform AUC24 calculations. Prospective data are needed to validate these conclusions.

Passy-Muir Speaking Valve Use in a Children's Hospital: An Interdisciplinary Approach

2008 ◽  
Vol 18 (2) ◽  
pp. 76-86 ◽  
Author(s):  
Lauren Hofmann ◽  
Joseph Bolton ◽  
Susan Ferry
Keyword(s):  
Tracheostomy Tube ◽  
Pediatric Population ◽  
Interdisciplinary Approach ◽  
Extended Period ◽  
Speech Development ◽  
Tube Placement ◽  
Background Information ◽  
Speaking Valve ◽  
Children's Hospital ◽  
Children’S Hospital

Abstract At The Children's Hospital of Philadelphia (CHOP) we treat many children requiring tracheostomy tube placement. With potential for a tracheostomy tube to be in place for an extended period of time, these children may be at risk for long-term disruption to normal speech development. As such, speaking valves that restore more normal phonation are often key tools in the effort to restore speech and promote more typical language development in this population. However, successful use of speaking valves is frequently more challenging with infant and pediatric patients than with adult patients. The purpose of this article is to review background information related to speaking valves, the indications for one-way valve use, criteria for candidacy, and the benefits of using speaking valves in the pediatric population. This review will emphasize the importance of interdisciplinary collaboration from the perspectives of speech-language pathology and respiratory therapy. Along with the background information, we will present current practices and a case study to illustrate a safe and systematic approach to speaking valve implementation based upon our experiences.

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