Publications by authors named "Lia Lowrie"

9 Publications

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Improving the Safety of an Emergency Department-Based Direct Admission Process at a Children's Hospital.

Pediatr Emerg Care 2020 Oct 13. Epub 2020 Oct 13.

From the Department of Pediatrics, Divisions of General Academic Pediatrics and Pediatric Emergency Medicine for Saint Louis University.

Objectives: Direct admission refers to admitting a patient to a unit avoiding usual entry points such as the emergency department. Inappropriate placement of direct admissions can result in rapid response activations, codes and unanticipated pediatric intensive care unit (PICU) transfers, which correlate with higher mortality and longer lengths of stay. The objective of the project was to improve the safety of the direct admission process as evidenced by decreasing the transfer of direct admission patients to the PICU within 6 hours.

Methods: Utilizing the model for improvement, a multidisciplinary team was assembled to improve our screening process and reduce unanticipated direct admission-to-PICU transfers within 6 hours of arrival. Our emergency department-based direct admission process includes screening vital signs (temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry) and a Pediatric Early Warning Score. Five Plan-Do-Study-Act cycles focused on role definition, improved documentation, referring facility and family awareness, improved visual management within the ED, and education of partner EMS and transport providers. The primary outcome was PICU transfer within 6 hours of direct admission arrival. Compliance with full screening was a process measure and number of direct admissions a balancing measure. Statistical process control charts and run charts were used to follow the measures.

Results: The total number of direct admissions from January 2014 to the end of data collection, June 2018, was 3070 patients. Screening protocol compliance improved from 56% to over 80% for the entire hospital. Unanticipated direct admission-to-PICU transfers decreased from a baseline of 1 every 98 patients to a special cause of 1 in 1126 patients.

Conclusions: By utilizing QI methodology our team was able to implement and sustain a direct admission process that was more consistent, easier to document and improved the safety of our patients. Our study demonstrates that screening direct admissions reliably and consistently can decrease the rate of unanticipated transfer to a higher level of care.
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October 2020

The authors reply.

Pediatr Crit Care Med 2018 08;19(8):798

Department of Pediatrics, St. Louis University, St. Louis, MO; Department of Pediatrics, Division of Pediatric Critical Care, St. Louis University, St. Louis, MO; Department of Pulmonology, Children's Hospital of Buffalo, Buffalo, NY.

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August 2018

Effects of a PICU Status Asthmaticus De-Escalation Pathway on Length of Stay and Albuterol Use.

Pediatr Crit Care Med 2018 07;19(7):658-664

Department of Pulmonology, Children's Hospital of Buffalo, Buffalo, NY.

Objectives: Evaluate the effects of an asthma de-escalation clinical pathway on selected outcomes for patients admitted to a PICU with status asthmaticus.

Design: Time series quality improvement trial.

Setting: PICU in a tertiary care children's hospital.

Patients: Children age 2-18 years old with a known diagnosis of asthma presenting with status asthmaticus.

Intervention: One-hundred five admissions to a PICU for status asthmaticus were treated according to a new de-escalation pathway between August 15, 2015, and August 30, 2016. This group was compared with a prepathway group of 141.

Measurements And Main Results: Primary outcome was variability in PICU length of stay. Secondary outcomes were median PICU length of stay, median hospital length of stay, and median duration a patient received continuous nebulized albuterol. The effectiveness of the intervention was tracked using control charts. The postpathway group demonstrated decreased variability of PICU length of stay and time receiving continuous albuterol. Statistically significant decreases were seen in median PICU length of stay (16 vs 13 hr; p = 0.0009), median duration a child spent receiving continuous nebulized albuterol (10.8 vs 7.3 hr; p = 0.0008), and median hospital length of stay (37 vs 31 hr; p = 0.02). Total number of asthma assessments completed by respiratory therapists increased from 741 to 1,087.

Conclusions: Implementation of a PICU asthma de-escalation pathway demonstrated statistical decrease in the reported measures for children with status asthmaticus. Although the clinical significance of these changes may be debatable, the results demonstrate that efforts to standardize asthma care in the PICU setting is an area in need of further study.
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July 2018

The impact of obesity on pediatric procedural sedation-related outcomes: results from the Pediatric Sedation Research Consortium.

Paediatr Anaesth 2015 Jul 27;25(7):689-97. Epub 2015 Mar 27.

Division of Pediatric Critical Care, Department of Pediatrics, University of Louisville, Louisville, KY, USA.

Objectives: To evaluate the impact of obesity on adverse events and required interventions during pediatric procedural sedation.

Methods: The Pediatric Sedation Research Consortium database of prospectively collected procedural sedation encounters was queried to identify patients for whom body mass index (BMI) could be calculated. Obesity was defined as BMI ≥95th percentile for age and gender. Sedation-related outcomes, adverse events, and therapeutic interventions were compared between obese and nonobese patients.

Results: For analysis, 28,792 records were eligible. A total of 5,153 patients (17.9%) were obese; they were predominantly male and older and had a higher median American Society of Anesthesiologists Physical Status classification (P < 0.001). Total adverse events were more common in obese patients (odds ratio [OR] 1.49, 95% confidence interval [1.31, 1.70]). Respiratory events (airway obstruction OR 1.94 [1.54, 2.44], oxygen desaturation OR 1.99 [1.50, 2.63], secretions OR 1.48 [1.01, 2.15], laryngospasm OR 2.30 [1.30, 4.05]), inability to complete the associated procedure (OR 1.96 [1.16, 3.30]), and prolonged recovery (OR 2.66 [1.26, 5.59]) were increased in obese patients. Obese patients more frequently required airway intervention including repositioning, suctioning, jaw thrust, airway adjuncts, and bag-valve-mask ventilation. Multivariate regression analysis demonstrated obesity to be independently associated with minor and moderate but not major adverse events.

Conclusions: Obesity is an independent risk factor for adverse respiratory events during procedural sedation and is associated with an increased frequency of airway interventions, suggesting that additional vigilance and expertise are required when sedating these patients.
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July 2015

Great expectations-defining quality in pediatric sedation: outcomes of a multidisciplinary consensus conference.

J Healthc Qual 2015 Mar-Apr;37(2):139-54

Purpose: Recognizing the inconsistencies in sedation practices, the Society for Pediatric Sedation convened this meeting to begin the process of defining quality as it relates to the field of pediatric sedation.

Scope: Millions of procedures are performed each year on children. Caring for children, even for routine procedures, can be challenging. Children may not have the ability to follow commands, tolerate painful stimuli, or even lie still for a diagnostic study. Therefore, pharmacologic sedation with medications designed to blunt the awareness of the patient and provide relief of pain and anxiety is necessary.

Methods: A multidisciplinary group of sedation providers and quality methodology experts met in November 2011. Through 2 days of didactics, small workgroups, and consensus discussions, the attendees met the objectives of exploring quality in pediatric sedation around the Institute of Medicine's () six aims of quality: Safe, Effective, Patient Centered, Timely, Efficient, and Equitable.

Results: The conference findings outlined in this document address the Agency for Healthcare Research and Quality's (AHRQ) mission of improving quality healthcare for all Americans, especially for underrepresented groups such as children. The conference outlines a key next step in defining and achieving quality in pediatric procedural sedation.
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November 2016

Development, implementation, and initial participant feedback of a pediatric sedation provider course.

Teach Learn Med 2013 ;25(3):249-57

University of Wisconsin School of Medicine and Public Health, Pediatrics, Madison, Wisconsin 53792, USA.

Background: No standardized educational curriculum exists for pediatric sedation practitioners. We sought to describe the curriculum and implementation of a pediatric sedation provider course and assess learner satisfaction with the course curriculum.

Description: The course content was determined by formulating a needs assessment using published sedation guidelines, reports of sedation related adverse events, and a survey of sedation practitioners. Students provided feedback regarding satisfaction with the course immediately following the course and 6 months later.

Evaluation: The course consisted of 5 didactic lectures, 1 small-group session, 6 simulation scenarios, a course syllabus, and a written examination. The course was conducted over 1 day at 3 different locations. Sixty-nine students completed the course and were uniformly satisfied with the course curriculum.

Conclusions: A standardized pediatric sedation provider course was developed for sedation practitioners and consisted of a series of lectures and simulation scenarios. Overall satisfaction with the course was positive.
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March 2014

Physiologic monitoring practices during pediatric procedural sedation: a report from the Pediatric Sedation Research Consortium.

Arch Pediatr Adolesc Med 2012 Nov;166(11):990-8

Department of Pediatrics, Section of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut 06511, USA.

Objectives: To describe the frequency of different physiologic monitoring modalities and combinations of modalities used during pediatric procedural sedation; to describe how physiologic monitoring varies among different classes of patients, health care providers (ie, ranging from anesthesiologists to emergency medicine physicians to nurse practitioners), procedures, and sedative medications employed; and to determine the proportion of sedations meeting published guidelines for physiologic monitoring. DESIGN This was a prospective, observational study from September 1, 2007, through March 31, 2011.

Setting: Data were collected in areas outside of the operating room, such as intensive care units, radiology, emergency departments, and clinics.

Participants: Thirty-seven institutions comprise the Pediatric Sedation Research Consortium that prospectively collects data on procedural sedation/anesthesia performed outside of the operating room in all children up to age 21 years.

Main Outcome Measures: Data including demographics, procedure performed, provider level, adverse events, medications, and physiologic monitors used are entered into a web-based system.

Results: Data from 114 855 subjects were collected and analyzed. The frequency of use of each physiologic monitoring modality by health care provider type, medication used, and procedure performed varied significantly. The largest difference in frequency of monitoring use was seen between providers using electrocardiography (13%-95%); the smallest overall differences were seen in monitoring use based on the American Society of Anesthesiologists classifications (1%-10%). Guidelines published by the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Society of Anesthesiologists for nonanesthesiologists were adhered to for 52% of subjects.

Conclusions: A large degree of variability exists in the use of physiologic monitoring modalities for pediatric procedural sedation. Differences in monitoring are evident between sedation providers, medications, procedures, and patient types.
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November 2012

Extubation failure in pediatric intensive care: a multiple-center study of risk factors and outcomes.

Crit Care Med 2003 Nov;31(11):2657-64

University of Minnesota Department of Pediatrics and Childrens Hospitals and Clinics, Minneapolis, USA.

Objective: To determine a contemporary failed extubation rate, risk factors, and consequences of extubation failure in pediatric intensive care units (PICUs). Three hypotheses were investigated: a) Extubation failure is in part disease specific; b) preexisting respiratory conditions predispose to extubation failure; and c) admission acuity scoring does not affect extubation failure.

Design: Twelve-month prospective, observational, clinical study.

Setting: Sixteen diverse PICUs in the United States.

Patients: Patients were 2,794 patients from the newborn period to 18 yrs of age experiencing a planned extubation trial.

Interventions: None.

Measurements And Main Results: A descriptive statistical analysis was performed, and outcome differences of the failed extubation population were determined. The extubation failure rate was 6.2% (174 of 2,794; 95% confidence interval, 5.3-7.1). Patient features associated with extubation failure (p <.05) included age < or =24 months; dysgenetic condition; syndromic condition; chronic respiratory disorder; chronic neurologic condition; medical or surgical airway condition; chronic noninvasive positive pressure ventilation; the need to replace the endotracheal tube on admission to the PICU; and the use of racemic epinephrine, steroids, helium-oxygen therapy (heliox), or noninvasive positive pressure ventilation within 24 hrs of extubation. Patients failing extubation had longer pre-extubation intubation time (failed, 148.7 hrs, SD +/- 207.8 vs. success, 107.9 hrs, SD +/- 171.3; p <.001), longer PICU length of stay (17.5 days, SD +/- 15.6 vs. 7.6 days, SD +/- 11.1; p <.001), and a higher mortality rate than patients not failing extubation (4.0% vs. 0.8%; p <.001). Failure was found to be in part disease specific, and preexisting respiratory conditions were found to predispose to failure whereas admission acuity did not.

Conclusion: A variety of patient features are associated with an increase in extubation failure rate, and serious outcome consequences characterize the extubation failure population in PICUs.
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November 2003