Introduction of a track and trigger system is associated with increased paediatric intensive care outreach utilisation and a trend towards improved patient outcomes in a tertiary children's hospital

Abstract

Patients requiring ECMO have acquired haemostatic disorders due to a vast interplay of factors including drugs, disease and device. In this heterogenous population it is impossible to define the isolated and combined effects of critical illness and ECMO on haemostasis.This study aimed to characterise changes in haemostasis attributable to ECMO in an in vivo ovine model using ROTEM ® and Multiplate ® analysis. In our validated model, 10 healthy sheep and 10 sheep with smoke-induced acute lung injury (S-ALI) were supported on venovenous ECMO. Heparin infusion commenced at 4 U/kg/h to achieve activated clotting time of 200-300 s. Samples were collected at baseline, pre-ECMO and 0.25, 1, 1.5 and 2 h post-ECMO initiation. Analysis included platelet counts, EXTEM and FIBTEM on ROTEM ® , and Multiplate ® analysis with ADP and collagen agonists.For both groups, platelet count remained within normal range. ECMO induced no significant changes to ADP or collagen-induced platelet aggregation or EXTEM clotting time. EXTEM clot formation time (CFT) was increased (p < 0.01) and EXTEM maximum clot firmness (MCF) (p < 0.001) was decreased compared to baseline for both groups throughout ECMO. A smaller decrease in FIBTEM-MCF was documented during ECMO in healthy sheep (p < 0.05) compared to sheep with S-ALI prior (p < 0.01).ECMO induces an increase in clot formation time and decrease in fibrinogen function and overall clot quality in healthy sheep. S-ALI prior to ECMO exacerbates these haemostatic alterations. Platelet number and function was maintained during ECMO, which, when assessed with the decrease in EXTEM-MCF and FIBTEM-MCF, suggests fibrinogen may be central to these haemostatic alterations.http://dx.

Validity and effectiveness of paediatric early warning systems and track and trigger tools for identifying and reducing clinical deterioration in hospitalised children: a systematic review

“…One uncontrolled before-after study in a community hospital (without RRT/MET) found significant postintervention reductions in rates of urgent calls to the in-house paediatrician (RR=0.23, 95% CI 0.11 to 0.46) and respiratory therapist70 (RR=0.36, 95% CI 0.13 to 0.95). Two uncontrolled before-after studies (with RRT/MET) found increases in rates of RRT calls72 (RR=1.59, 95% CI 0.33 to 1.90) and outreach team calls66 (RR=1.92, 95% CI 1.79 to 2.07). One study found no change in rates of RRT calls 71…”

“…There was also limited evidence for early warning systems reducing PICU transfers or calls for urgent review. Again, a small number of uncontrolled before-after studies reported significant reductions postintervention,15 17 63 but several other studies reported significant increases in transfers or calls for review66 72 or no postintervention changes. We did find moderate evidence across four studies—including a controlled before-after study, a multicentre interrupted time series study and a multicentre cluster randomised trial—for early warning system interventions reducing rates of early critical interventions in children transferred to PICU 64 65 68 69.…”

Development, implementation and evaluation of an early warning system improvement programme for children in hospital: the PUMA mixed-methods study

“…105 Two uncontrolled before-and-after studies (with RRTs/METs) found increases in the rates of RRT calls (RR 1.59, 95% CI 1.33 to 1.90) 107 and outreach team calls (RR 1.92, 95% CI 1.79 to 2.07). 101 One study found no change in the rate of RRT calls. 106 Paediatric intensive care unit transfers…”

“…Seventeen interventions involved the introduction of a new PTTT, 38,[46][47][48][49]84,[96][97][98][99][100][101][102][103][104][105][106][107] one intervention introduced a mandatory triggering element to an existing PTTT 106 and one study reported a large, multicentre analysis of MET introduction with no details on PTTT use. 108 Twelve interventions included the introduction of a new MET or RRT, 38,[46][47][48][49]84,[96][97][98][99][100]104 and four further interventions 87,89,100,106 introduced a new PTTT in a hospital with an existing MET or RRT.…”

“…102 One study did not report the PTTT used, 97 and 10 studies used a variety of calling criteria and local modifications to validated tools that had not been evaluated for validity. [46][47][48][49]96,99,101,103,104,106 Mortality (ward or hospital wide)…”