Year in review in Intensive Care Medicine, 2008: III. Paediatrics, Ethics, outcome research and critical care organization, sedation, pharmacology and miscellanea

Excerpt

Increasingly in paediatric intensive care, as in the adult sphere, the intensivist’s focus is increasingly guided towards not only reducing mortality but also to ensuring that survival is morbidity-free. Baghurst et al. [1] reported on the applicability of sequential control charts for monitoring of the quality of paediatric intensive care using risk-adjusted probabilities of death estimated by the Paediatric Index of Mortality version 2 (PIM2). A total of 10,710 patient records submitted to the Australia and New Zealand Paediatric Intensive Care registry from 8 PICU’s were used in the report. During the 2-year monitoring period the investigators demonstrated that their methodology was able to detect one ‘alarm’ for poor PICU performance and one ‘alarm’ for better than expected PICU performance. In their paper, the authors present a detailed description of sequential analysis methodologies and describe their potential prospective use as tools for monitoring the performance of intensive care units. They caution that ‘alarms’ for poor or excessively good performance are arbitrarily set and are not necessarily indicative of ‘real’ problems. Alarms should, however, act as triggers for investigation to ascertain whether the data is sound and if so whether true clinical over or underperformance exists. Numa et al. [2] undertook a study to determine whether outcomes were influenced by time of admission to an Australian tertiary paediatric intensive care unit without 24 h per day in-house intensivist cover. Evening, night and weekend cover by staff intensivists was provided mainly by telephone with discretionary return to hospital to support resident paediatric staff. The authors found that a lack of in-house intensivist was not associated with any increase in risk-adjusted mortality or increased length of stay. They attribute these findings to a combination of relatively experienced junior staff and the effectiveness of telephone backup and discretionary attendance from intensivists after hours. Two studies in 2008 looked at the quality of survival of children after undergoing intensive care. In a case-control study, Elison et al. [3] reported on a detailed neuropsychological follow-up of 16 children, with mean age 9.44 ± 2.85 years, tested a mean of 4.8 ± 1.4 months following hospital discharge. They detected the presence of impaired memory and attention in children following acute illness and links between memory anomalies and emotional/behavioural problems. These findings, if replicated in a larger study, are very important to children and their parents and teachers. Knoester et al. [4] also reported on early neurocognitive sequelae of intensive care but in addition reported information on physical outcomes. They determined that 69% of children had detectable physical sequelae 3 months after PICU discharge. Whilst 30% of sequelae were attributed to previously unknown illness, 39% were acquired of which 8% were related to complications of PICU procedures. Finally, in the area of patient safety and quality, Burmester et al. [5] reported on the apparent benefit of the introduction of a structured prescription education programme and standardised prescription template in a paediatric cardiac ICU. The total number of prescription errors fell from a baseline of 16.8% of prescriptions to 4.8% after the implementation of the measures and this was associated with a small but statistically significant reduction in the incidence of Adverse Drug Events. Weight-based variations in drug dosing are often quoted as a factor in the known high incidence of drug errors in paediatric practice. Disappointingly, tenfold miscalculations which are particularly common and dangerous in children if the decimal point is misplaced during calculations showed no improvement with the studied interventions. This report highlights the need for regular ongoing education in critical care units which typically have high prescription volumes and often see high turnover of staff, particularly ‘junior’ prescribers such as resident medical staff. …