Management of Pediatric Septic Shock and Acute Respiratory Distress Syndrome in Thailand: A Survey of Pediatricians

Introduction: Pediatric septic shock and acute respiratory distress syndrome (pARDS) are major causes of morbidity and mortality in pediatric intensive care units (PICUs). While standardized guidelines for sepsis and pARDS are published regularly, their implementation and adherence to guidelines are different in resource-rich and resource-limited countries. The purpose of this study was to conduct a survey to ascertain variation in current clinician-reported practice in pediatric septic shock and acute respiratory distress syndrome, and the clinician skills in a variety of hospital settings throughout Thailand.Methods: We conducted an electronic survey in pediatricians throughout the country between August 2020 and February 2021 using multiple choice questions and clinical case scenarios based on the 2017 American College of Critical Care Medicine's Consensus guideline for pediatric and neonatal septic shock and the 2015 Pediatric Acute Lung Injury Consensus Conference.Results: The survey elicited responses from 255 pediatricians (125 general pediatricians, 38 pulmonologists, 27 cardiologists, 32 intensivists, and 33 other subspecialists), with 54.5% of the respondents having <5 years of PICU experience. Among the six sepsis scenarios, 72.5 and 78.4% of the respondents had good adherence to the guidelines for managing fluid refractory shock and sedation for intubation, respectively. The ICU physicians reported greater adherence during more complex shock. In ARDS scenarios, 80.8% of the respondents reported having difficulty diagnosing ARDS mimic conditions and used lesser PEEP than the recommendation. Acceptance of permissive hypercapnia and mild hypoxemia was accepted by 62.4 and 49.4% of respondents, respectively. The ICU physicians preferred decremental PEEP titration, whereas general pediatricians preferred incremental PEEP titration.Conclusion: This survey variation could be the result of resource constraints, knowledge gaps, or ambiguous guidelines. Understanding the perspective and rationale for variation in pediatricians' practices is critical for successful guideline implementation.

Trends in Prehospital Blood, Crystalloid, and Colloid Administration in Accordance With Changes in Tactical Combat Casualty Care Guidelines

ABSTRACT Introduction Hemorrhage is the leading threat to the survival of battlefield casualties. This study aims to investigate the types of fluids and blood products administered in prehospital trauma encounters to discover the effectiveness of Tactical Combat Casualty Care (TCCC) recommendations. Materials and Methods This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry with a focus on prehospital fluid and blood administration in conjunction with changes in the TCCC guidelines. We collected demographic information on each patient. We categorized receipt of each fluid type and blood product as a binary variable for each casualty and evaluated trends over 2007–2020 both unadjusted and controlling for injury severity and mechanism of injury. Results Our original dataset comprised 25,897 adult casualties from January 1, 2007 through March 17, 2020. Most (97.3%) of the casualties were male with a median age of 25. Most (95.5%) survived to hospital discharge, and 12.2% of the dataset received fluids of any kind. Medical personnel used crystalloids in 7.4% of encounters, packed red blood cells in 2.0%, and whole blood in 0.5% with very few receiving platelets or freeze-dried plasma. In the adjusted model, we noted significant year-to-year increases in intravenous fluid administration from 2014 to 2015 and 2018 to 2019, with significant decreases noted in 2008–2009, 2010–2012, and 2015–2016. We noted no significant increases in Hextend used, but we did note significant decreases in 2010–2012. For any blood product, we noted significant increases from 2016 to 2017, with decreases noted in 2009–2013, 2015–2016, and 2017–2018. Overall, we noted a general spike in all uses in 2011–2012 that rapidly dropped off 2012–2013. Crystalloids consistently outpaced the use of blood products. We noted a small upward trend in all blood products from 2017 to 2019. Conclusions Changes in TCCC guidelines did not immediately translate into changes in prehospital fluid administration practices. Crystalloid fluids continue to dominate as the most commonly administered fluid even after the 2014 TCCC guidelines changed to use of blood products over crystalloids. There should be future studies to investigate the reasons for delay in guideline implementation and efforts to improve adherence.

Cough and cold medicine prescription rates can be significantly reduced by active intervention

Our aim was to construct and test an intervention programme to eradicate cough and cold medicine (CCM) prescriptions for children treated in a nationwide healthcare service company. The study was carried out in the largest private healthcare service company in Finland with a centralised electronic health record system allowing for real-time, doctor-specific practice monitoring. The step-by-step intervention consisted of company-level dissemination of educational materials to doctors and families, educational staff meetings, continuous monitoring of prescriptions, and targeted feedback. Outreach visits were held in noncompliant units. Finally, those physicians who most often prescribed CCM were directly contacted. During the intervention period (2017–2020), there were more than one million paediatric visits. Prescriptions of CCMs to children were completely eradicated in 41% of units and the total number of CCM prescriptions decreased from 6738 to 744 (89%). During the fourth intervention year, CCMs containing opioid derivatives were prescribed for only 0.2% of children aged < 2 years. The decrease in prescriptions was greatest in general practitioners (5.2 to 1.1%). In paediatricians, the prescription rates decreased from 1.5 to 0.2%. The annual costs of CCMs decreased from €183,996 to €18,899 (89.7%). For the intervention, the developers used 343 h and the attended doctors used 684 h of work time during the 4-year intervention. The costs used for developing, implementing, reporting, evaluating, communicating, and data managing formed approximately 11% of total intervention costs.Conclusion: The study showed that a nationwide systematic intervention to change cough medicine prescription practices is feasible and requires only modest financial investments. What is Known:• Cough and cold medicines (CCM) are not effective or safe, especially for children aged 6 years.• Although the use of CCMs has been declining, caregivers continue to administer CCMs to children, and some physicians still prescribe them even for preschool children. What is New:• A nationwide systematic intervention can significantly and cost effectively change CCM prescription habits of paediatricians, general practitioners, and other specialists.• Electronic health records provide additional tools for operative guideline implementation and real-time quality monitoring, including recommendations of useless or harmful treatments.

Midwives’ Survey of Their Weight Management Practice Before and After the GLOWING Guideline Implementation Intervention: A Pilot Cluster Randomised Controlled Trial

Background: Weight management is a priority for maternity services due to pregnancy risks and long-term health implications for women and babies. Pregnancy interventions significantly improve maternal diet, physical activity, weight, and some pregnancy outcomes. There are complex barriers, underpinned by self-efficacy, to midwives’ implementation of UK guidelines. The GLOWING intervention uses social cognitive theory (SCT) to address evidence-based barriers to practice, with the aim of supporting midwives’ implementation of guidelines into routine practice.Methods: An external rehearsal pilot cluster randomised controlled trial in four NHS Trusts (clusters) in England, UK. Clusters were randomised to intervention arm where all eligible midwives received the intervention, or control arm which received no intervention. A random sample of 100 midwives were invited to complete questionnaires pre- and post-intervention. UK guideline recommendations were grouped into communication-related behaviours (weight and risk communication) and support/intervention-related behaviours (diet/nutrition, physical activity, weight management, referrals/signposting). Questionnaires were developed using SCT constructs (self-efficacy, outcome expectancies, intentions, behaviours) and 7-point Likert scale. Data were converted to a 0-100 scale, where higher scores were more positive. Descriptive statistics compared intervention and control arms, pre- and post-intervention.Results: Seventy-four midwives consented and 68 returned questionnaires. Pre-intervention, self-efficacy for support/intervention-related behaviours scored lowest. In the control arm, there was limited difference between the pre- and post-intervention scores. Post-intervention, the mean scores were consistently higher in the intervention than control arm, particularly for support/intervention self-efficacy (71.4, SD 17.1 and 58.4, SD 20.1). Mean self-efficacy was higher post-intervention than pre-intervention for all behaviour categories in the intervention arm: weight communication (76.3, SD 16.7 vs. 67.2, SD 21.1), risk communication (79.4, SD 16.4, vs. 68.6, SD 14.9), diet/nutrition/physical activity (76.4, SD 16.0 vs. 49.3, SD 16.5), weight management (72.1, SD 18.3 vs. 48.3, SD 19.8), referrals/signposting (63.3, SD 26.0 vs. 47.9, SD 17.3), and consistently higher than controls.Conclusions: This study supports the theoretical models used to develop GLOWING, particularly that low self-efficacy is core to implementation barriers. Results suggest that the intervention is successfully targeting self-efficacy, which could have a positive impact on guideline implementation. A future definitive trial is required to determine effectiveness and cost-effectiveness. Trial registration: ISRCTN46869894, retrospectively registered 25/05/2016, http://isrctn.com/ISRCTN46869894

Blood pressure and cholesterol measurements in primary care: cross-sectional analyses in a dynamic cohort

BackgroundGuidelines on cardiovascular risk management (CVRM) recommend blood pressure (BP) and cholesterol measurements every five years in men ≥40 and (post-menopausal) women ≥50 years.AimEvaluate CVRM guideline implementation.Design & settingCross-sectional analyses in a dynamic cohort using primary care electronic health record (EHR) data from the Julius General Practitioners’ Network (n=388,929).MethodWe assessed trends (2008–2018) in the proportion of patients with at least one measurement (BP and cholesterol) every one, two, and five years, in those with a history of (1) cardiovascular disease (CVD) and diabetes, (2) diabetes only, (3) CVD only, (4) cardiovascular risk assessment (CRA) indication based on other medical history, or (5) no CRA indication. We evaluated trends over time using logistic regression mixed model analyses.ResultsTrends in annual BP and cholesterol measurement increased for patients with a history of CVD from 37.0% to 48.4% (P<0.001) and 25.8% to 40.2% (P<0.001). In the five-year window 2014–2018, BP and cholesterol measurements were performed in respectively 78.5% and 74.1% of all men ≥40 years and 82.2% and 78.5% in all women ≥50 years. Least measured were patients without a CRA indication: men 60.2% and 62.4%; women 55.5% and 59.3%.ConclusionThe fairly high frequency of CVRM measurements available in the EHR of patients in primary care suggests an adequate implementation of the CVRM guideline. As nearly all individuals visit the general practitioner once within a five-year time window, improvement of CVRM remains very well possible, especially in those without a CRA indication.

Use and effects of implementation strategies for practice guidelines in nursing: a systematic review

Background Practice guidelines can reduce variations in nursing practice and improve patient care. However, implementation of guidelines is complex and inconsistent in practice. It is unclear which strategies are effective at implementing guidelines in nursing. This review aimed to describe the use and effects of implementation strategies to facilitate the uptake of guidelines focused on nursing care. Methods We conducted a systematic review of five electronic databases in addition to the Cochrane Effective Practice and Organization of Care (EPOC) Group specialized registry. Studies were included if implementation of a practice guideline in nursing and process or outcome of care provided by nurses were reported. Two reviewers independently screened studies, assessed study quality, extracted data, and coded data using the EPOC taxonomy of implementation strategies. For those strategies not included in the EPOC taxonomy, we inductively categorized these strategies and generated additional categories. We conducted a narrative synthesis to analyze results. Results The search identified 46 papers reporting on 41 studies. Thirty-six studies used a combination of educational materials and educational meetings. Review findings show that multicomponent implementation strategies that include educational meetings, in combination with other educational strategies, report positive effects on professional practice outcomes, professional knowledge outcomes, patient health status outcomes, and resource use/expenditures. Twenty-three of the 41 studies employed implementation strategies not listed within the EPOC taxonomy, including adaptation of practice guidelines to local context (n = 9), external facilitation (n = 14), and changes to organizational policy (n = 3). These implementation strategies also corresponded with positive trends in patient, provider, and health system outcomes. Conclusions Nursing guideline implementation may benefit from using the identified implementation strategies described in this review, including participatory approaches such as facilitation, adaptation of guidelines, and organizational policy changes. Further research is needed to understand how different implementation strategy components work in a nursing context and to what effect. As the field is still emerging, future reviews should also explore guideline implementation strategies in nursing in quasi or non-experimental research designs and qualitative research studies.

Evaluation of high-dose insulin/euglycemia therapy for suspected β-blocker or calcium channel blocker overdose following guideline implementation

Purpose High-dose insulin/euglycemia (HDIE) is targeted therapy for β-blocker and calcium channel blocker overdose. A guideline using concentrated insulin infusions (20 units/mL), aggressive monitoring, and supportive recommendations was implemented. We sought to evaluate safety before and after HDIE guideline implementation and describe the patient population, insulin doses, supplemental dextrose, vasopressor use, hospital and intensive care unit (ICU) lengths of stay, and mortality. Methods Retrospective review was performed of patients receiving HDIE before and after guideline implementation at an academic medical center and community hospital from March 2011 through December 2019. Information on patient and overdose demographics, ingestion data, vital signs, interventions, adverse events, and disposition was collected. Data are presented descriptively with comparisons using Mann-Whitney U analysis and Fisher’s exact tests. Results During the study period, 27 patients were treated with HDIE, 10 before guideline implementation (37%; mean [SD] initial insulin dose, 0.49 [0.35] units/kg/h; mean [SD] maximum insulin dose, 2.25 [3.29] units/kg/h; median [interquartile range] duration, 10 [5.5-18.75] hours) and 17 after guideline implementation (63%; mean [SD] initial insulin dose, 1.01 [0.34] units/kg/h; mean [SD] maximum insulin dose, 2.99 [5.05] unit/kg/h; median [interquartile range] duration, 16 [11.5-37] hours). Hypoglycemia, hypokalemia, and volume overload occurred in 80% vs 29% (P = 0.018), 40% vs 53% (P = 0.69), and 50% vs 65% (P = 0.69) of patients in the preguideline vs postguideline group, respectively. Most patients received an initial insulin bolus (85%; mean [SD], 70.3 [21.8] units, 0.9 [0.26] units/kg) and vasopressor infusion (85%). More postguideline patients received a dextrose infusion with a concentration of 20% or higher (93% vs 50%, P = 0.015). There were no differences in cardiac arrest, in-hospital mortality, or hospital or ICU length of stay between the groups. Conclusion Hypoglycemia was reduced using an HDIE guideline and concentrated insulin.

141. Effectiveness of a Multipronged Approach to Improve Prophylactic Antibiotic Prescribing in Patients Undergoing Trans-Arterial Chemoembolization

Background In our institution, the significant use of broad-spectrum antibiotics for antibiotic prophylaxis (AP) in trans-arterial chemoembolization (TACE) was operator dependent and not evidence based. Hence, an AP guideline was developed with the Department of Vascular and Interventional Radiology and launched in May 2019, following department roadshows and creation of user-friendly electronic AP order sets. We analyzed the effectiveness and outcomes of our multipronged approach towards improving the standardization of AP prescribing. Methods This was a retrospective study of TACE procedures from November 2018 to March 2020, pre and post guideline implementation (Figure 1). Single IV cefazolin 2g dose (or IV clindamycin 600mg in the setting of β-lactam allergy) before TACE in patients with an uncompromised sphincter of Oddi was recommended. Patients with active infections prior to TACE were excluded. AP was deemed inappropriate if it deviated from guidelines (antibiotic choice and/or duration). Primary outcome was AP appropriateness and 30-day TACE related infections. Figure 1. Timeline of our multipronged approach Results Seventy patients were included. There were no differences in baseline demographics pre and post implementation (Table 1). Following guideline implementation, there was a significant improvement in AP used for TACE. AP appropriateness pre-implementation and post-implementation was 14/31 (45.2%) and 37/39 (94.9%) respectively (p&lt; 0.001). Guideline compliant antibiotics were selected more frequently (14 [45.2%] vs 38 [97.4%], p&lt; 0.001), and more patients received single dose AP (22 [71.0%] vs 38 [97.4%], p=0.004). Of the 18 patients who did not receive guideline recommended AP, 16 (88.9%) received IV ceftriaxone and metronidazole, 1 (5.6%) IV amoxicillin/clavulanic acid, and 1 (5.6%) IV ciprofloxacin. Ten patients received a prolonged course of AP with a median duration of 6 days (IQR 4.3, 6.5). There were no significant differences in 30-day TACE related infections (1 [3.2%] vs 2 [5.1%], p=1.000) and 30-day mortality (1 [3.2%] vs 1 [2.6%], p=1.000). No patient had surgical site skin infection. Conclusion Our multipronged approach improved AP prescribing in patients undergoing TACE. Single dose IV cefazolin prophylaxis for TACE did not compromise safety outcomes in the post implementation review. Disclosures All Authors: No reported disclosures