Development of a Standardized Clinical Assessment and Management Plan for Pediatric Acute Respiratory Distress Syndrome

Abstract

Pediatric acute respiratory distress syndrome (PARDS) is one of the most challenging patient populations for a clinician to manage with mortality between 8 and 31%. The project was designed to identify patients with PARDS, implement management guidelines with the goal of standardizing practice. Our objectives were to describe the development and implementation of a protocolized approach to identify patients with PARDS and institute ventilator management guidelines. Patients who met criteria for moderate or severe PARDS as per the Pediatric Acute Lung Injury Consensus Conference (PALICC) definitions were identified using the best practice alert (BPA) in the electronic health record (EHR). Patients who did not meet exclusion criteria qualified for management using the Standardized Clinical Assessment and Management Plan (SCAMP), a quality improvement (QI) methodology with iterative cycles. The creation of a BPA enabled identification of patients with PARDS. With our second cycle, the number of false BPA alerts due to incorrect data decreased from 66.7 (68/102) to 29.2% (19/65; p < 0.001) and enrollment increased from 48.3 (14/29) to 73.2% (30/41; p = 0.03). Evaluation of our statistical process control chart (SPC) demonstrated a shift in the adherence with the tidal volume guideline. Overall, we found that SCAMP methodology, when used in the development of institutional PARDS management guidelines, allows for development of a process to aid identification of patients and monitor adherence to management guidelines. This should eventually allow assessment of impact of deviations from clinical practice guidelines.

Keywords

pediatric acute respiratory distress syndrome - quality improvement methodology - standardized clinical assessment and management plan - clinical decision support tools

Authors' Contributions

P.R. designed the study, drafted the initial manuscript, and approved the final manuscript as submitted. M.W. designed the study, revised the manuscript, and approved the final manuscript as submitted. All other authors helped conceptualize the study, reviewed and revised the manuscript, and approved the final manuscript as submitted.

Publikationsverlauf

Eingereicht: 08. September 2020

Angenommen: 09. November 2020

Artikel online veröffentlicht:
04. Januar 2021

• References

• 1 Dahlem P, van Aalderen WMC, Hamaker ME, Dijkgraaf MGW, Bos AP. Incidence and short-term outcome of acute lung injury in mechanically ventilated children. Eur Respir J 2003; 22 (06) 980-985
• 2 Zimmerman JJ, Akhtar SR, Caldwell E, Rubenfeld GD. Incidence and outcomes of pediatric acute lung injury. Pediatrics 2009; 124 (01) 87-95
• 3 Randolph AG, Meert KL, O'Neil ME. et al; Pediatric Acute Lung Injury and Sepsis Investigators Network. The feasibility of conducting clinical trials in infants and children with acute respiratory failure. Am J Respir Crit Care Med 2003; 167 (10) 1334-1340
• 4 Cheifetz IM. Pediatric acute respiratory distress syndrome. Respir Care 2011; 56 (10) 1589-1599
• 5 Pediatric Acute Lung Injury Consensus Conference Group. Pediatric acute respiratory distress syndrome: consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16 (05) 428-439
• 6 Weiss CH, Baker DW, Tulas K. et al. A critical care clinician survey comparing attitudes and perceived barriers to low tidal volume ventilation with actual practice. Ann Am Thorac Soc 2017; 14 (11) 1682-1689
• 7 Khemani RG, Smith L, Lopez-Fernandez YM. et al; Pediatric Acute Respiratory Distress syndrome Incidence and Epidemiology (PARDIE) Investigators, Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Paediatric acute respiratory distress syndrome incidence and epidemiology (PARDIE): an international, observational study. Lancet Respir Med 2019; 7 (02) 115-128
• 8 Khemani RG, Parvathaneni K, Yehya N. et al. PEEP lower than the ARDS network protocol is associated with higher pediatric ARDS mortality. Am J Respir Crit Care Med 2018; 198: 77-89
• 9 ARDSnet, NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary. Accessed on September 13, 2016 at: http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf
• 10 Schwede M, Lee RY, Zhuo H. et al. Clinician recognition of the Acute Respiratory Distress Syndrome: risk factors for under-recognition and trends over time. Crit Care Med 2020; 48 (06) 830-837
• 11 Bellani G, Laffey JG, Pham T. et al; LUNG SAFE Investigators, ESICM Trials Group. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA 2016; 315 (08) 788-800
• 12 Standardized Clinical Assessment and Management Plan, Institute for Relevant Clinical Data and Analytics (IRCDA). Accessed May 2019 at: https://www.guidestar.org/profile/38-3854536.
• 13 Prosci ADKAR Model. Accessed June 2019 at: https://www.prosci.com/adkar/adkar-model/.
• 14 Walsh MA, Merat M, La Rotta G. et al. Airway pressure release ventilation improves pulmonary blood flow in infants after cardiac surgery. Crit Care Med 2011; 39 (12) 2599-2604
• 15 Varpula T, Jousela I, Niemi R, Takkunen O, Pettilä V. Combined effects of prone positioning and airway pressure release ventilation on gas exchange in patients with acute lung injury. Acta Anaesthesiol Scand 2003; 47 (05) 516-524
• 16 Garner W, Downs JB, Stock MC, Räsänen J. Airway pressure release ventilation (APRV). A human trial. Chest 1988; 94 (04) 779-781
• 17 Stock MC, Downs JB, Frolicher DA. Airway pressure release ventilation. Crit Care Med 1987; 15 (05) 462-466
• 18 Habashi NM. Other approaches to open-lung ventilation: airway pressure release ventilation. Crit Care Med 2005; 33 (Suppl. 03) S228-S240
• 19 Gupta P, Green JW, Tang X. et al. Comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure. JAMA Pediatr 2014; 168 (03) 243-249
• 20 Valentine SL, Nadkarni VM, Curley MAQ. Pediatric acute lung injury consensus conference group. Non-pulmonary treatments for pediatric acute respiratory distress syndrome: Proceedings from the pediatric acute lung injury consensus conference. Pediatr Crit Care Med 2015; 16: s74-s85
• 21 Flori HR, Church G, Liu KD, Gildengorin G, Matthay MA. Positive fluid balance is associated with higher mortality and prolonged mechanical ventilation in pediatric patients with acute lung injury. Crit Care Res Pract 2011; 2011: 854142
• 22 Sarnaik AP, Meert KL, Pappas MD, Simpson PM, Lieh-Lai MW, Heidemann SM. Predicting outcome in children with severe acute respiratory failure treated with high-frequency ventilation. Crit Care Med 1996; 24 (08) 1396-1402
• 23 Yehya N, Topjian AA, Lin R, Berg RA, Thomas NJ, Friess SH. High frequency oscillation and airway pressure release ventilation in pediatric respiratory failure. Pediatr Pulmonol 2014; 49 (07) 707-715
• 24 Rettig JS, Smallwood CD, Walsh BK. et al. High frequency oscillatory ventilation in pediatric acute lung injury: A multicenter international experience. Crit Care Med 2015; 43 (12) 2660-2667
• 25 Lalgudi Ganesan S, Jayashree M, Chandra Singhi S, Bansal A. Airway pressure release ventilation in pediatric acute respiratory syndrome. A randomized controlled trial. Am J Respir Crit Care Med 2018; 198 (09) 1199-1207
• 26 Hirshberg EL, Lanspa MJ, Peterson J. et al. Randomized feasibility trial of a low tidal volume-airway pressure release ventilation protocol compared with traditional airway pressure release ventilation and volume control ventilation protocols. Crit Care Med 2018; 46 (12) 1943-1952
• 27 Lloyd RC. Quality Health Care: A Guide to Developing and Using Indicators. 2nd ed.. Burlington, MA: Jones and Bartlett Learning; 2019
• 28 Zaglam N, Jouvet P, Flechelles O, Emeriaud G, Cheriet F. Computer-aided diagnosis system for the acute respiratory distress syndrome from chest radiographs. Comput Biol Med 2014; 52: 41-48
• 29 Newth CJL, Khemani RG, Jouvet PA, Sward KA. Mechanical ventilation and decision support in pediatric intensive care. Pediatr Clin North Am 2017; 64 (05) 1057-1070