Sustained Improvement in the Performance of Rapid Sequence Intubation Five Years after a Quality Improvement Initiative.

Unlabelled: Many quality improvement interventions do not lead to sustained improvement, and the sustainability of healthcare interventions remains understudied. We conducted a time-series analysis to determine whether improvements in the safety of rapid sequence intubation (RSI) in our academic pediatric emergency department were sustained 5 years after a quality improvement initiative.

Methods: There were 3 study periods: baseline (April 2009-March 2010), improvement (July 2012-December 2013), and operational (January 2014-December 2018).

Reducing the incidence of oxyhaemoglobin desaturation during rapid sequence intubation in a paediatric emergency department.

Objectives: Rapid sequence intubation (RSI) is the standard for definitive airway management in emergency medicine. In a video-based study of RSI in a paediatric emergency department (ED), we reported a high degree of process variation and frequent adverse effects, including oxyhaemoglobin desaturation (SpO2<90%). This report describes a multidisciplinary initiative to improve the performance and safety of RSI in a paediatric ED.

Quality improvement project to reduce infiltration and extravasation events in a pediatric hospital.

A safety event response team at Cincinnati Children's Hospital Medical Center developed and tested improvement strategies to reduce peripheral intravenous (PIV) infiltration and extravasation injuries. Improvement activities included development of the touch-look-compare method for hourly PIV site assessment, staff education and mandatory demonstration of PIV site assessment, and performance monitoring and sharing of compliance results. We observed a significant reduction in the injury rate immediately following implementation of the interventions that corresponded with monitoring compliance in performing hourly assessments on patients with a PIV, but this was not sustained.

Reduction in hypoglycemic events in critically ill patients on continuous insulin following implementation of a treatment guideline.

Background: Hyperglycemia is common in critically ill children and appears to be associated with poor outcomes. However, the incidence of hypoglycemia while attempting glycemic control using an insulin infusion may be as high as 25% and hypoglycemia may be an independent risk factor for mortality in critically ill children.

Methods: An improvement team developed a guideline for initiation and maintenance of insulin infusions for hyperglycemia in critically ill, nondiabetic patients in the pediatric intensive care unit.

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Background: Narcotics are responsible for many adverse drug events in children and there has been an increase in opioid oversedation events in hospitalised patients.

Objectives: To use improvement methods to prevent perioperative opioid oversedation adverse events while continuing to provide appropriate pain control.

Methods: Interventions included revising the post-anaesthesia order form so that prescribers could choose only one narcotic and one dose for moderate pain and one narcotic and one dose for severe pain, modifying a nursing tool to provide more objective criteria for assessing patient sedation level, and restructuring the pain service.

Abnormal X: autosome ratio, but normal X chromosome inactivation in human triploid cultures.

Background: X chromosome inactivation (XCI) is that aspect of mammalian dosage compensation that brings about equivalence of X-linked gene expression between females and males by inactivating one of the two X chromosomes (Xi) in normal female cells, leaving them with a single active X (Xa) as in male cells. In cells with more than two X's, but a diploid autosomal complement, all X's but one, Xa, are inactivated. This phenomenon is commonly thought to suggest 1) that normal development requires a ratio of one Xa per diploid autosomal set, and 2) that an early event in XCI is the marking of one X to be active, with remaining X's becoming inactivated by default.

Normal histone modifications on the inactive X chromosome in ICF and Rett syndrome cells: implications for methyl-CpG binding proteins.

Background: In mammals, there is evidence suggesting that methyl-CpG binding proteins may play a significant role in histone modification through their association with modification complexes that can deacetylate and/or methylate nucleosomes in the proximity of methylated DNA. We examined this idea for the X chromosome by studying histone modifications on the X chromosome in normal cells and in cells from patients with ICF syndrome (Immune deficiency, Centromeric region instability, and Facial anomalies syndrome). In normal cells the inactive X has characteristic silencing type histone modification patterns and the CpG islands of genes subject to X inactivation are hypermethylated.