Healthcare delivery factors associated with the perception of saturation of emergency care services: The opinion of the professionals

Fonament. La saturació a urgències comporta conseqüències negatives sobre la qualitat assistencial. És important saber quins factors de l'assistència en relació amb la saturació preocupen més el personal sanitari amb la finalitat de corregir-los. Objectiu. Conèixer la importància dels factors de l'assistència relacionats amb la saturació a urgències segons la percepció dels professionals. Mètode. Estudi descriptiu. Durant la primera setmana de juliol del 2014, s'administra una enquesta anònima al personal d'urgències. L'enquesta valora diferents aspectes sobre la saturació en aquest departament. Consta de dues parts: en la primera es valoren dotze variables numèriques i cinc de temps, en escala d'importància de l'1 al 10; i en la segona es dona un valor quantitatiu als ítems més rellevants. Resultats. Es recullen 51 enquestes, 29 d'infermeria i 22 de pediatres. Els tres ítems més rellevants en la primera part corresponen a: nombre de pacients de nivell II-III pendents de visitar (mitjana 9,3; IC 95%: 9,1-9,5), temps d'espera dels pacients de nivell II-III fins a ser atesos (mitjana 9,3; IC95%: 9,0-9,5) i nombre de procediments d'infermeria pendents (mitjana 8,2; IC95%: 7,7-8,7). Respecte a aquests ítems, de mediana, els professionals consideren normal que hi hagi tres pacients pendents de ser visitats, amb un temps d'espera de deu minuts i tres procediments per fer. A partir de deu pacients, quaranta minuts i set procediments, es creu que les urgències estan saturades. Conclusions. La quantitat de pacients de nivell II-III pendents de ser visitats i el seu temps d'espera, junt amb la càrrega de treball d'infermeria, són els aspectes que influeixen més en la percepció de saturació a urgèncie

Procalcitonin and lung ultrasound algorithm to diagnose severe pneumonia in critical paediatric patients (PROLUSP study). A randomised clinical trial

Lung ultrasound (LUS) in combination with a biomarker has not yet been studied. We propose a clinical trial where the primary aims are: 1. To assess whether an algorithm with LUS and procalcitonin (PCT) may be useful for diagnosing bacterial pneumonia; 2. To analyse the sensitivity and specificity of LUS vs chest X-ray (CXR). A 3-year clinical trial. Inclusion criteria: children younger than 18 years old with suspected pneumonia in a Paediatric Intensive Care Unit. Patients will be randomised into two groups: Experimental Group: LUS will be performed as first lung image. Control Group: CXR will be performed as first pulmonary image. Patients will be classified according to the image and the PCT: a) PCT 1 ng/mL, antibiotic therapy is recommended. This algorithm will help us to diagnose bacterial pneumonia and to prescribe the correct antibiotic treatment. A reduction of antibiotics per patient, of the treatment length, and of the exposure to ionizing radiation and in costs is expected

A training plan to implement lung ultrasound for diagnosing pneumonia in children

Lung ultrasound (LUS) for critical patients requires trained operators to perform them, though little information exists on the level of training required for independent practice. The aims were to implement a training plan for diagnosing pneumonia using LUS and to analyze the inter-observer agreement between senior radiologists (SRs) and pediatric intensive care physicians (PICPs). Prospective longitudinal and interventional study conducted in the Pediatric Intensive Care Unit of a tertiary hospital. Following a theoretical and practical training plan regarding diagnosing pneumonia using LUS, the concordance between SRs and the PICPs on their LUS reports was analyzed. Nine PICPs were trained and tested on both theoretical and practical LUS knowledge. The mean exam mark was 13.5/15. To evaluate inter-observer agreement, a total of 483 LUS were performed. For interstitial syndrome, the global Kappa coefficient (K) was 0.51 (95% CI 0.43-0.58). Regarding the presence of consolidation, K was 0.67 (95% CI 0.53-0.78), and for the consolidation pattern, K was 0.82 (95% CI 0.79-0.85), showing almost perfect agreement. Our training plan allowed PICPs to independently perform LUS and might improve pneumonia diagnosis. We found a high inter-observer agreement between PICPs and SRs in detecting the presence and type of consolidation on LUS

Risk factors and incidence of invasive bacterial infection in severe bronchiolitis: the RICOIB prospective study

Background: Bacterial infection (BI), both community-acquired (CA-BI) and hospital-acquired (HAI), might present as a severe complication in patients with bronchiolitis. This study aimed to describe BI in children with severe bronchiolitis, and to define risk factors for BI. Methods: This was a prospective, descriptive study that included infants admitted to the pediatric intensive care unit (PICU) due to bronchiolitis between 2011 and 2017. The BROSJOD score was calculated to rate the severity of bronchiolitis. Results: Inclusion of 675 patients, with a median age of 47 days (IQR 25-99). 175 (25.9%) patients developed BI, considered HAI in 36 (20.6%). Patients with BI had higher BROSJOD score, PRISM III, and required invasive mechanical ventilation and inotropic support more frequently (p 12 (OR 2.435, 95%CI 1.379-4.297) and bacterial co-infection (OR 2.294 95%CI 1.051-5.008). Concerning HAI, an independent association was shown with mechanical ventilation longer than 7 days (OR 5.139 95%CI 1.802-14.652). Infants with BI had longer PICU and hospital stay (p 12 may alert the presence of CA-BI, especially pneumonia. Patients with BI have higher morbidity and mortality

Characteristics and management of patients with SARS-CoV2 infection admitted to pediatric intensive care units: Data analysis of the Spanish national multicenter registry

SARS-COV-2; Mechanical ventilation; Pediatric intensive careSARS-COV-2; Ventilació mecànica; Cures intensives pediàtriquesSARS-COV-2; Ventilacion mecanica; Cuidados intensivos pediátricosIntroduction The purpose of this study is to describe the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) disease characteristics and management in children admitted to the pediatric intensive care units (PICU). Methods The present study was based on a national multicentric prospective registry including PICU patients with SARS-CoV2 infection or symptoms of multisystem inflammatory syndrome in children (MIS-C). Results A total of 298 patients were admitted to 41 different Spanish PICUs. A total of 76% of them were previously healthy. The most frequent manifestation was MIS-C (69.8%). On admission, 59.4% of patients did not have respiratory distress, and only 17.4% needed conventional mechanical ventilation (MV). The need for MV was associated with age (incidence rate ratios [IRR] 1.21, p < .012), pediatric sequential organ failure assessment score (p-SOFA) Score (IRR 1.12, p = .001), and need for transfusion (IRR 4.5, p < .004) in MIS-C patients, and with vasoactive drug use (IRR 2.73, p = .022) and the diagnosis of acute respiratory distress syndrome (IRR 2.83, p = .018) in patients admitted for other reasons. During the first day of admission, 56% of patients met shock criteria and 50.7% needed vasoactive drugs. In MIS-C patients, their use was associated with higher p-SOFA score (IRR 1.06, p < .001) and with the diagnosis of shock (IRR 5.78, p < .001). In patients without MIS-C, it was associated with higher p-SOFA score (IRR 1.05, p = .022). The mortality rate was 3%, being lower in MIS-C patients compared to patients admitted for other reasons (0.5% vs. 9.4%, p < .001). It was also lower in previously healthy patients compared to patients with previous comorbidities (0.9% vs. 9.7%, p < .001). Conclusions Severe SARS-CoV2 infection is uncommon in the pediatric population. In our series, respiratory distress was rare, being MIS-C the most frequent cause of PICU admission related to SARS-CoV2. In most cases, the course of the disease was mild except in children with previous diseases.This study has been founded by the Carlos III Health Institute (ISCIII) through the COVID-19 found. Ref. COV20-00944. The founder had no role in study design, data collection, analysis and interpretation

End-of-life care in a pediatric intensive care unit: the impact of the development of a palliative care unit

Background: The purpose of this paper is to describe how end-of-life care is managed when life-support limitationis decided in a Pediatric Intensive Care Unit and to analyze the influence of the further development of the Palliative Care Unit. Methods: A 15-year retrospective study of children who died after life-support limitation was initiated in a pediatric intensive care unit. Patients were divided into two groups, pre- and post-palliative care unit development. Epidemiological and clinical data, the decision-making process, and the approach were analyzed. Data was obtained from patient medical records. Results: One hundred seventy-five patients were included. The main reason for admission was respiratory failure (86/175). A previous pathology was present in 152 patients (61/152 were neurological issues). The medical team and family participated together in the decision-making in 145 cases (82.8%). The family made the request in 10 cases (9 vs. 1, p = 0.019). Withdrawal was the main life-support limitation (113/175), followed by withholding lifesustaining treatments (37/175). Withdrawal was more frequent in the post-palliative group (57.4% vs. 74.3%, p = 0.031). In absolute numbers, respiratory support was the main type of support withdrawn. Conclusions: The main cause of life-support limitation was the unfavourable evolution of the underlying pathology. Families were involved in the decision-making process in a high percentage of the cases. The development of the Palliative Care Unit changed life-support limitation in our unit, with differences detected in the type of patient and in the strategy used. Increased confidence among intensivists when providing end-of-life care, and the availability of a Palliative Care Unit may contribute to improvements in the quality of end-of-life care

The different manifestations of COVID-19 in adults and children: a cohort study in an intensive care unit

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has collapsed health systems worldwide. In adults, the virus causes severe acute respiratory distress syndrome (ARDS), while in children the disease seems to be milder, although a severe multisystem inflammatory syndrome (MIS-C) has been described. The aim was to describe and compare the characteristics of the severe COVID-19 disease in adults and children. Methods: This prospective observational cohort study included the young adults and children infected with SARS-CoV-2 between March-June 2020 and admitted to the paediatric intensive care unit. The two populations were analysed and compared focusing on their clinical and analytical characteristics and outcomes. Results: Twenty patients were included. There were 16 adults (80%) and 4 children (20%). No mortality was recorded. All the adults were admitted due to ARDS. The median age was 32 years (IQR 23.3-41.5) and the most relevant previous pathology was obesity (n = 7, 43.7%). Thirteen (81.3%) needed mechanical ventilation, with a median PEEP of 13 (IQR 10.5-14.5). Six (37.5%) needed inotropic support due to the sedation. Eight (50%) developed a healthcare-associated infection, the most frequent of which was central line-associated bloodstream infection (n = 7, 71.4%). One patient developed a partial pulmonary thromboembolism, despite him being treated with heparin. All the children were admitted due to MIS-C. Two (50%) required mechanical ventilation. All needed inotropic support, with a median vasoactive-inotropic score of 27.5 (IQR 17.5-30). The difference in the inotropic requirements between the two populations was statistically significant (37.5% vs. 100%, p < 0.001). The biomarker values were higher in children than in adults: mid-regional pro-adrenomedullin 1.72 vs. 0.78 nmol/L (p = 0.017), procalcitonin 5.7 vs. 0.19 ng/mL (p = 0.023), and C-reactive protein 328.2 vs. 146.9 mg/L (p = 0.005). N-terminal pro-B-type natriuretic peptide and troponins were higher in children than in adults (p = 0.034 and p = 0.039, respectively). Conclusions: Adults and children had different clinical manifestations. Adults developed severe ARDS requiring increased respiratory support, whereas children presented MIS-C with greater inotropic requirements. Biomarkers could be helpful in identifying susceptible patients, since they might change depending on the clinical features

Severe manifestations of SARS-CoV-2 in children and adolescents: from COVID-19 pneumonia to multisystem inflammatory syndrome: a multicentre study in pediatric intensive care units in Spain

Background Multisystem inflammatory syndrome temporally associated with COVID-19 (MIS-C) has been described as a novel and often severe presentation of SARS-CoV-2 infection in children. We aimed to describe the characteristics of children admitted to Pediatric Intensive Care Units (PICUs) presenting with MIS-C in comparison with those admitted with SARS-CoV-2 infection with other features such as COVID-19 pneumonia. Methods A multicentric prospective national registry including 47 PICUs was carried out. Data from children admitted with confirmed SARS-CoV-2 infection or fulfilling MIS-C criteria (with or without SARS-CoV-2 PCR confirmation) were collected. Clinical, laboratory and therapeutic features between MIS-C and non-MIS-C patients were compared. Results Seventy-four children were recruited. Sixty-one percent met MIS-C definition. MIS-C patients were older than non-MIS-C patients (p = 0.002): 9.4 years (IQR 5.5-11.8) vs 3.4 years (IQR 0.4-9.4). A higher proportion of them had no previous medical history of interest (88.2% vs 51.7%, p = 0.005). Non-MIS-C patients presented more frequently with respiratory distress (60.7% vs 13.3%, p < 0.001). MIS-C patients showed higher prevalence of fever (95.6% vs 64.3%, p < 0.001), diarrhea (66.7% vs 11.5%, p < 0.001), vomits (71.1% vs 23.1%, p = 0.001), fatigue (65.9% vs 36%, p = 0.016), shock (84.4% vs 13.8%, p < 0.001) and cardiac dysfunction (53.3% vs 10.3%, p = 0.001). MIS-C group had a lower lymphocyte count (p < 0.001) and LDH (p = 0.001) but higher neutrophil count (p = 0.045), neutrophil/lymphocyte ratio (p < 0.001), C-reactive protein (p < 0.001) and procalcitonin (p < 0.001). Patients in the MIS-C group were less likely to receive invasive ventilation (13.3% vs 41.4%, p = 0.005) but were more often treated with vasoactive drugs (66.7% vs 24.1%, p < 0.001), corticosteroids (80% vs 44.8%, p = 0.003) and immunoglobulins (51.1% vs 6.9%, p < 0.001). Most patients were discharged from PICU by the end of data collection with a median length of stay of 5 days (IQR 2.5-8 days) in the MIS-C group. Three patients died, none of them belonged to the MIS-C group. Conclusions MIS-C seems to be the most frequent presentation among critically ill children with SARS-CoV-2 infection. MIS-C patients are older and usually healthy. They show a higher prevalence of gastrointestinal symptoms and shock and are more likely to receive vasoactive drugs and immunomodulators and less likely to need mechanical ventilation than non-MIS-C patients

Severe manifestations of SARS-CoV-2 in children and adolescents: from COVID-19 pneumonia to multisystem inflammatory syndrome: a multicentre study in pediatric intensive care units in Spain

Background Multisystem inflammatory syndrome temporally associated with COVID-19 (MIS-C) has been described as a novel and often severe presentation of SARS-CoV-2 infection in children. We aimed to describe the characteristics of children admitted to Pediatric Intensive Care Units (PICUs) presenting with MIS-C in comparison with those admitted with SARS-CoV-2 infection with other features such as COVID-19 pneumonia. Methods A multicentric prospective national registry including 47 PICUs was carried out. Data from children admitted with confirmed SARS-CoV-2 infection or fulfilling MIS-C criteria (with or without SARS-CoV-2 PCR confirmation) were collected. Clinical, laboratory and therapeutic features between MIS-C and non-MIS-C patients were compared. Results Seventy-four children were recruited. Sixty-one percent met MIS-C definition. MIS-C patients were older than non-MIS-C patients (p = 0.002): 9.4 years (IQR 5.5–11.8) vs 3.4 years (IQR 0.4–9.4). A higher proportion of them had no previous medical history of interest (88.2% vs 51.7%, p = 0.005). Non-MIS-C patients presented more frequently with respiratory distress (60.7% vs 13.3%, p < 0.001). MIS-C patients showed higher prevalence of fever (95.6% vs 64.3%, p < 0.001), diarrhea (66.7% vs 11.5%, p < 0.001), vomits (71.1% vs 23.1%, p = 0.001), fatigue (65.9% vs 36%, p = 0.016), shock (84.4% vs 13.8%, p < 0.001) and cardiac dysfunction (53.3% vs 10.3%, p = 0.001). MIS-C group had a lower lymphocyte count (p < 0.001) and LDH (p = 0.001) but higher neutrophil count (p = 0.045), neutrophil/lymphocyte ratio (p < 0.001), C-reactive protein (p < 0.001) and procalcitonin (p < 0.001). Patients in the MIS-C group were less likely to receive invasive ventilation (13.3% vs 41.4%, p = 0.005) but were more often treated with vasoactive drugs (66.7% vs 24.1%, p < 0.001), corticosteroids (80% vs 44.8%, p = 0.003) and immunoglobulins (51.1% vs 6.9%, p < 0.001). Most patients were discharged from PICU by the end of data collection with a median length of stay of 5 days (IQR 2.5–8 days) in the MIS-C group. Three patients died, none of them belonged to the MIS-C group. Conclusions MIS-C seems to be the most frequent presentation among critically ill children with SARS-CoV-2 infection. MIS-C patients are older and usually healthy. They show a higher prevalence of gastrointestinal symptoms and shock and are more likely to receive vasoactive drugs and immunomodulators and less likely to need mechanical ventilation than non-MIS-C patients

Healthcare delivery factors associated with the perception of saturation of emergency care services: The opinion of the professionals

Fonament. La saturació a urgències comporta conseqüències negatives sobre la qualitat assistencial. És important saber quins factors de l'assistència en relació amb la saturació preocupen més el personal sanitari amb la finalitat de corregir-los. Objectiu. Conèixer la importància dels factors de l'assistència relacionats amb la saturació a urgències segons la percepció dels professionals. Mètode. Estudi descriptiu. Durant la primera setmana de juliol del 2014, s'administra una enquesta anònima al personal d'urgències. L'enquesta valora diferents aspectes sobre la saturació en aquest departament. Consta de dues parts: en la primera es valoren dotze variables numèriques i cinc de temps, en escala d'importància de l'1 al 10; i en la segona es dona un valor quantitatiu als ítems més rellevants. Resultats. Es recullen 51 enquestes, 29 d'infermeria i 22 de pediatres. Els tres ítems més rellevants en la primera part corresponen a: nombre de pacients de nivell II-III pendents de visitar (mitjana 9,3; IC 95%: 9,1-9,5), temps d'espera dels pacients de nivell II-III fins a ser atesos (mitjana 9,3; IC95%: 9,0-9,5) i nombre de procediments d'infermeria pendents (mitjana 8,2; IC95%: 7,7-8,7). Respecte a aquests ítems, de mediana, els professionals consideren normal que hi hagi tres pacients pendents de ser visitats, amb un temps d'espera de deu minuts i tres procediments per fer. A partir de deu pacients, quaranta minuts i set procediments, es creu que les urgències estan saturades. Conclusions. La quantitat de pacients de nivell II-III pendents de ser visitats i el seu temps d'espera, junt amb la càrrega de treball d'infermeria, són els aspectes que influeixen més en la percepció de saturació a urgèncie