| 11 th Annual Pediatric Critical Care Colloquium |
| Session/Time | Technology/Monitoring/Sat, 10:00 - 11:00 AM |
| Title | Reduction of Blood Gases in a Pediatric ICU (PICU): A Process Improvement |
| Author | ES Yong, OD Timmons, MW Uhl, L Linda, K, Biles, J Scheval, D. James, T Schena, T Cooley, M Rathbun, S Cecil and G Dukes |
| Affiliation | Carolinas Medical Center, Charlotte, NC |
| Introduction | We identified an overuse of arterial and capillary blood gases (BGs) in the PICU. We invited a multi-disciplinary group of physicians, respiratory therapists, and nurses to identify perceived indications for obtaining BGs. We intended to reduce the number of BGs. |
| Method | A process improvement team Nvas formed for our 8 bed medical / suraical PICU. The piCU is located in a community based academic teaching hospital staffed by upper level pediatric and emergency medicine residents and 3 pediatric intensivists. Commonly used indications for obtaining Bc;s were listed. We determined that most indications could be eliminated and the remainder could be reduced with a thorough patient assessment. An advanced patient assessment education process was implemented in July 1997. We compared consecutive PICU patients admitted during the six months before implementation (n=298) to those admitted in the next eleven months (n=506). We also examined the subset of mechanically ventilated patients. Data were obtained from the PICU clinical and respiratory care databases. Data included BGs, PICU lencth of -tay (LOS), and risk of normality (PRISM) for all patients. Data for ventilated patients included BGs per ventilator day, duration of mechanical ventilation and PRISM. Data are presented as mean ± standard deviation or median as noted and compared by t-test. |
| Result | The process improvement orcup concluded that most pivotal decisions about airway, ventilator, and metabolic management could be made without BGs. Mechanical ventilation standina orders and new onset DKA clinical paths were chanaed. Education was the lar-est component of the process and focused on clinical assessment, increased use of end tidal C02 MOnitOrina., and continued use of pulse oxinietry. In the six months before iraplementation an averace of 229 BGs per month were obtained in the PICU. In the ne,\t eleven months we averaced 31 BGs per month, a decrease of 86.5% (p<0.05). Median PICU LOS for all patients %vas 1.6 d before and 1.4 d after the intervention (NS, p="0.239)." j ,lean PRISivt mortality estimate for all patients was 0.06 + 0.16 before and 0.05 + 0.14 ifter implementation, respectively (NS, p="0.314)." For intubated patients, BGs per ventilator da%, decreased from 3.2 to 0.5, a reduction of 84.40/o (p<0.05). The iiiediin dtir.itioji of i-necliiiiical ventilation xvis 1.7 d before and 1.4 d after iiiipleinciititioii (NS, p="0.323)." Pl'\IS,.\i mortality estimate for ventilated patients vas 0. l- 0.23 be orc in(i 0. I I 0.22 if'ter the process (NS, p="0.603)." <0.05). Median PICU LOS for all patients was 1.6 d before and 1.4 d after the intervention(NS, p=0.239). Mean PRISM mortality estimate for all patients was 0.06 + 0.16 before and 0.05 + 0.14 after implementation, respectively (NS, p=0.314) For intubated patients, Bgs per ventilator day decreased from 3.2 to 0.5, a reduction of 84.4% (p<0.05). The median duration of mechanical ventilation was 1.7 d before and 1.4 d after implementation (NS, p=0.323). Mean PRISM mortality estimate for ventilated patients was 0.12 + 0.23 before and 0.11 + 0.22 after the process (NS, p=0.603) |
| Conclusion | Quality patient and ventilator management was not determined nor driven by blood gases. We did not experience an increase in PICU length of stay, mortality risk or duration of mechanical ventilation. We speculate that the assessment skills for all care givers were enhanced. |
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