Retrospective Evaluation of the Epidemiology and Practice Variation of Dexmedetomidine Use in Invasively Ventilated Pediatric Intensive Care Admissions, 2007-2013

OBJECTIVES: The study assessed dexmedetomidine utilization and practice variation over time in ventilated pediatric intensive care unit (PICU) patients; and evaluated differences in hospital outcomes between high- and low-dexmedetomidine utilization hospitals. STUDY DESIGN: This serial cross-sectional analysis used administrative data from PICU admissions in the pediatric health information system (37 US tertiary care pediatric hospitals). Included admissions from 2007 to 2013 had simultaneous dexmedetomidine and invasive mechanical ventilation charges, <18 years of age, excluding neonates. Patient and hospital characteristics were compared as well as hospital-level severity-adjusted indexed length of stay (LOS), charges, and mortality. RESULTS: The utilization of dexmedetomidine increased from 6.2 to 38.2 per 100 ventilated PICU patients among pediatric hospitals. Utilization ranged from 3.8 to 62.8 per 100 in 2013. Few differences in patient demographics and no differences in hospital-level volume/severity of illness measures between high- and low-utilization hospitals occurred. No differences in hospital-level, severity-adjusted indexed outcomes (LOS, charges, and mortality) were found. CONCLUSION: Wide practice variation in utilization of dexmedetomidine for ventilated PICU patients existed even as use has increased sixfold. Higher utilization was not associated with increased hospital charges or reduced hospital LOS. Further work should define the expected outcome benefits of dexmedetomidine and its appropriate use

Cross-sectional comparison of critically ill pediatric patients across hospitals with various levels of pediatric care

BACKGROUND: Inpatient administrative data sources describe the care provided to hospitalized children. The Kids' Inpatient Database (KID) provides nationally representative estimates, while the Pediatric Health Information System (PHIS, a consortium of pediatric facilities) derives more detailed information from revenue codes. The objective was to contextualize a diagnosis and procedure-based definition of critical illness to a revenue-based definition; then compare it across hospitals with different levels of pediatric care. METHODS: This retrospective, cross-sectional study utilized the 2009 KID, and 2009 inpatient discharges from the PHIS database. Patients <21 years of age (excluding neonates) were included to focus on pediatric critical illness. Critical illness was defined as: (1) critical care services (CC services) using diagnosis and procedures codes and (2) intensive care unit (ICU) care using revenue codes. Demographics, invasive procedures, and categories of critical illness were compared using Chi square and survey-weighted methods. The definitions of critical illness were compared in PHIS hospitals. CC services populations identified in General Hospitals, Pediatric Facilities, and Freestanding Children's hospitals (from KID) were compared to those in PHIS hospitals. RESULTS: Among PHIS hospitals, critically ill discharges identified by CC services accounted for 37.7% of ICU care. CC services discharges were younger and had greater proportion of respiratory illness and invasive procedure use. Critically ill patients identified by CC services in PHIS hospitals were statistically similar to those in Freestanding Children's hospitals. Pediatric Facilities and General Hospitals had more adolescents with more traumas. CC services patients in general hospitals had lower use of invasive procedures and predominance of trauma, respiratory illness, mental health issues, and general infections. Freestanding children's hospitals discharged 22% of the estimated 96,700 CC services cases. Similar proportions of critically ill patients were seen in Pediatric Facilities (31%) and General Hospitals (33%). CONCLUSION: The CC services definition captured a more severely ill fraction of critically ill children. Critically ill discharges from PHIS hospitals can likely be extrapolated to Freestanding Children's hospitals and Pediatric Facilities. General Hospitals, which provide a significant amount of pediatric critical care, are different. Studies utilizing administrative data can benefit from multiple data sources, which balance the individual strengths and weaknesses

Big data in healthcare - the promises, challenges and opportunities from a research perspective: A case study with a model database

Recent advances in data collection during routine health care in the form of Electronic Health Records (EHR), medical device data (e.g., infusion pump informatics, physiological monitoring data, and insurance claims data, among others, as well as biological and experimental data, have created tremendous opportunities for biological discoveries for clinical application. However, even with all the advancement in technologies and their promises for discoveries, very few research findings have been translated to clinical knowledge, or more importantly, to clinical practice. In this paper, we identify and present the initial work addressing the relevant challenges in three broad categories: data, accessibility, and translation. These issues are discussed in the context of a widely used detailed database from an intensive care unit, Medical Information Mart for Intensive Care (MIMIC III) database

The factors associated with high-quality communication for critically ill children

OBJECTIVE: Timely, high quality communication with families is essential to family-centered decision-making. Quality communication is represented by widespread documentation of prognostic, goals-of-care conversations (PGOCC) in the pediatric intensive care unit (PICU) and should occur without variation by patient characteristics. METHODS: Cohort included 645 PICU admissions in the top decile of risk of mortality on admission over six years. Electronic medical records were used to determine PGOCC, diagnosis on admission and complex chronic condition (CCC) status. Multivariate logistic regression and time-to-event analyses were used. RESULTS: Overall, 31% had a documented PGOCC. 51% had CCC status. 11% had an oncologic, 13% had a cardiovascular diagnosis on admission. 94% of patients who died in the PICU had PGOCC documented, but among the 200 patients with documented PGOCC, 78% did not die in the PICU. Oncologic diagnosis on admission was associated with a higher likelihood of PGOCC compared to non-CCC patients (ARR=1.86; SE=0.26) whereas no other diagnosis category reached the level of statistical significance. Median time from admission to PGOCC was 2 days. Age, gender and CCC status were not associated with whether a PGOCC was documented or with time from admission to PGOCC documentation. 45% of PGOCC in the cohort and 50% of conversations in patients with CCC were documented by PICU physicians. CONCLUSIONS: This study reveals the opportunity for improvement in documentation of PGOCC for critically ill children. It raises the questions of why there is variation of PGOCC across disease categories and whether PGOCC should be considered a quality measure for family-centered care

Pediatric Cardiac Tumors: A 45-year, Single Institution Review

Background: Cardiac tumors in children are rare. Of the cases reported in the literature, nearly all are benign and managed conservatively. Methods: This is a retrospective, observational study of pediatric patients <18 years who presented for surgical evaluation of a cardiac tumor, between 1969 and 2014 at a tertiary care children’s hospital. Presentation, pathology, management, and outcomes were evaluated. Results: Over the last 45 years, 64 patients were evaluated for surgical resection of a cardiac tumor. Rhabdomyoma was the most common neoplasm (58%), and 17% of the tumors had malignant pathologies. While 42% of benign cardiac neoplasms required surgical intervention for significant hemodynamic concerns, 73% of malignant neoplasms underwent radical excision, if possible, followed by adjuvant chemotherapy. Despite a 37% mortality in patients with malignant pathology, an aggressive surgical approach can yield long-term survival in some patients. There were no deaths among patients with benign tumors and 17% had postoperative complications mostly related to mitral regurgitation. Conclusion: Cardiac tumors in children are rare but can be managed aggressively with good outcomes. Benign tumors have an excellent survival with most complications related to tumor location. Malignant tumors have a high mortality rate, but surgery and adjuvant chemotherapy allow for prolonged survival in selected patients

Variation in extubation failure rates after neonatal congenital heart surgery across Pediatric Cardiac Critical Care Consortium hospitals

OBJECTIVE: In a multicenter cohort of neonates recovering from cardiac surgery, we sought to describe the epidemiology of extubation failure and its variability across centers, identify risk factors, and determine its impact on outcomes. METHODS: We analyzed prospectively collected clinical registry data on all neonates undergoing cardiac surgery in the Pediatric Cardiac Critical Care Consortium database from October 2013 to July 2015. Extubation failure was defined as reintubation less than 72 hours after the first planned extubation. Risk factors were identified using multivariable logistic regression with generalized estimating equations to account for within-center correlation. RESULTS: The cohort included 899 neonates from 14 Pediatric Cardiac Critical Care Consortium centers; 14% were premature, 20% had genetic abnormalities, 18% had major extracardiac anomalies, and 74% underwent surgery with cardiopulmonary bypass. Extubation failure occurred in 103 neonates (11%), within 24 hours in 61%. Unadjusted rates of extubation failure ranged from 5% to 22% across centers; this variability was unchanged after adjusting for procedural complexity and airway anomaly. After multivariable analysis, only airway anomaly was identified as an independent risk factor for extubation failure (odds ratio, 3.1; 95% confidence interval, 1.4-6.7; P = .01). Neonates who failed extubation had a greater median postoperative length of stay (33 vs 23 days, P < .001) and in-hospital mortality (8% vs 2%, P = .002). CONCLUSIONS: This multicenter study showed that 11% of neonates recovering from cardiac surgery fail initial postoperative extubation. Only congenital airway anomaly was independently associated with extubation failure. We observed a 4-fold variation in extubation failure rates across hospitals, suggesting a role for collaborative quality improvement to optimize outcomes

Tracheostomy Following Surgery for Congenital Heart Disease: 14-year Institutional Experience

Background: Tracheostomy following congenital heart disease (CHD) surgery is a rare event and associated with significant mortality. Hospital survival has been reported from 20% to 40%. Late mortality for these patients is not well characterized. Methods: We performed a retrospective observational study of patients who had a tracheostomy following CHD surgery (excluding isolated patent ductus arteriosus ligation) between January 2000 and December 2013. Patients were categorized into single-ventricle or biventricular physiology groups. Demographics, genetic syndromes, pulmonary disease, and comorbidities were collected. Outcomes including hospital survival, long-term survival, and weaning from positive pressure ventilation are reported. Bivariate and time-to-event models were used. Results: Over a 14-year period, 61 children (0.9% incidence) had a tracheostomy placed following CHD surgery. There were 12 single-ventricle patients and 49 biventricular patients. Prematurity, genetic syndromes, lung/airway disease, and other comorbidities were common in both CHD groups. Gastrostomy tubes were used more frequently in biventricular physiology patients (91.8%) versus single-ventricle patients (66.7%, P = .04). Survival to hospital discharge was 50% in the single-ventricle group compared to 86% in biventricular patients (P = .01). Long-term survival continued to be poor in the single-ventricle group comparatively (three years, 27.8% vs 64.8%, P = .01). Gastrostomy tube placement was independently associated with survival in both groups (P = .002). Conclusion: Tracheostomy is performed following many types of surgery for CHD and is commonly associated with other comorbidities. Both hospital and long-term survival are substantially lower in children with single-ventricle physiology as compared to patients with biventricular physiology

Tracheostomy after Surgery for Congenital Heart Disease: An Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database

Background Information concerning tracheostomy after operations for congenital heart disease has come primarily from single-center reports. We aimed to describe the epidemiology and outcomes associated with postoperative tracheostomy in a multi-institutional registry. Methods The Society of Thoracic Surgeons Congenital Heart Database (2000 to 2014) was queried for all index operations with the adverse event “postoperative tracheostomy” or “respiratory failure, requiring tracheostomy.” Patients with preoperative tracheostomy or weighing less than 2.5 kg undergoing isolated closure of patent ductus arteriosus were excluded. Trends in tracheostomy incidence over time from January 2000 to June 2014 were analyzed with a Cochran-Armitage test. The patient characteristics associated with operative mortality were analyzed for January 2010 to June 2014, including deaths occurring up to 6 months after transfer of patients to long-term care facilities. Results From 2000 to 2014, the incidence of tracheostomy after operations for congenital heart disease increased from 0.11% in 2000 to a high of 0.76% in 2012 (p < 0.0001). From 2010 to 2014, 648 patients underwent tracheostomy. The median age at operation was 2.5 months (25th, 75th percentile: 0.4, 7). Prematurity (n = 165, 26%), genetic abnormalities (n = 298, 46%), and preoperative mechanical ventilation (n = 275, 43%) were common. Postoperative adverse events were also common, including cardiac arrest (n = 131, 20%), extracorporeal support (n = 87, 13%), phrenic or laryngeal nerve injury (n = 114, 18%), and neurologic deficit (n = 51, 8%). The operative mortality was 25% (n = 153). Conclusions Tracheostomy as an adverse event of operations for congenital heart disease remains rare but has been increasingly used over the past 15 years. This trend and the considerable mortality risk among patients requiring postoperative tracheostomy support the need for further research in this complex population

Extubation Failure after Neonatal Cardiac Surgery: A Multicenter Analysis

Objectives To describe the epidemiology of extubation failure and identify risk factors for its occurrence in a multicenter population of neonates undergoing surgery for congenital heart disease. Study design We conducted a prospective observational study of neonates ≤30 days of age who underwent cardiac surgery at 7 centers within the US in 2015. Extubation failure was defined as reintubation within 72 hours of the first planned extubation. Risk factors were identified with the use of multivariable logistic regression analysis and reported as OR with 95% CIs. Multivariable logistic regression analysis was conducted to examine the relationship between extubation failure and worse clinical outcome, defined as hospital length of stay in the upper 25% or operative mortality. Results We enrolled 283 neonates, of whom 35 (12%) failed their first extubation at a median time of 7.5 hours (range 1-70 hours). In a multivariable model, use of uncuffed endotracheal tubes (OR 4.6; 95% CI 1.8-11.6) and open sternotomy of 4 days or more (OR 4.8; 95% CI 1.3-17.1) were associated independently with extubation failure. Accordingly, extubation failure was determined to be an independent risk factor for worse clinical outcome (OR 5.1; 95% CI 2-13). Conclusions In this multicenter cohort of neonates who underwent surgery for congenital heart disease, extubation failure occurred in 12% of cases and was associated independently with worse clinical outcome. Use of uncuffed endotracheal tubes and prolonged open sternotomy were identified as independent and potentially modifiable risk factors for the occurrence of this precarious complication