There have been real advances in the area of pain and anxiety management in pediatric patients in the urgent and emergent settings. The focus on the ''patient experience'' and not just the obtaining of a diagnosis and a treatment has forced many Emergency Departments to reassess how they address pain and anxiety. Many new products and methods, whether pharmacological based or not, are being utilized to make the patient encounter less stressful and less painful for both children and families. Additionally, it has been recognized that appreciating the importance of the patient's developmental age is essential in choosing the correct modality of intervention. Yet again, we learn children are not just small adults.

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BackgroundVentilator-associated tracheitis (VAT) is a common intensive-care unit entity considered in febrile patients with endotracheal intubation or with tracheostomy. Prospective-Audit-And-Feedback activities had identified an overall increased and high inter-provider-variability in the use of antibiotics for VAT. By developing a VAT-specific guideline, we intended primarily to decrease the amount of respiratory fluid cultures (RFCx) submitted, and secondly decrease the overall antibiotic use (AU) in the PICU, while not increasing the incidence of ventilator-associated events (VAE).MethodsA multidisciplinary team developed a guideline for patients with fever or change in baseline respiratory support with endotracheal intubation or with tracheostomy who had no radiographic evidence of pneumonia consisting of three parts: A) When to send an RFCx, B) Diagnosis of VAT, C) Antibiotic management of VAT: A) To obtain a RFCx, patient needed to have an abnormal white cell count (WBC) ( <5 K/uL or >14.5 K/uL) AND purulent or increased amount of endotracheal secretions PLUS either abnormal body temperature (T <36°C or ≥38.3°C) or change in baseline respiratory support. B) A diagnosis of VAT is allowed if RFCx shows Gram stain with ≥+3 WBC AND ≥+3 bacteria. C) Empiric antibiotic treatment with antipseudomonal activity (informed by previous RFCx if exist) to be started after RFCx have been obtained. Reassessment and possible modification at 48H based on final RFCx results. Duration of AU to be limited to 5 days. Guideline education was completed at multiple PICU meetings from September 2017 through June 2018. Manual audits were used to analyze adherence to the guideline. Data on RFCx order utilization, ventilator days, and AU from January 2017 to December 2018 were analyzed.ResultsSince the initiation of the guideline, we observed a downward trend of RFCx orders (Fig1.A) with an average decrease of 19% after guideline implementation. The overall AU (Fig1.B) in PICU decreased by an average of 24% while the incidence of VAE has remained stable.ConclusionEfforts to standardize diagnosis and treatment of VAT in patients with endotracheal intubation or tracheostomy resulted in a decreased number of RFCx, and reduced overall AU without increasing the risk of VAE. Disclosures All authors: No reported disclosures.