Minutes of NEPICC Meeting
Dec 5, 2016- 10:00am- 2:00pm
UMass Medical School, Worcester MA- Aaron Lazarre Medical Research Building
Attendees in person: Scot Bateman (UMass), Dave Tiber (UMass), Stacey Valentine
(UMass), Christine McKiernan (Baystate), Kristy Parker (Baystate), Carol Pineda
(Tufts), Steffi Gauguet (UMass) Lauren Fortier (UMass)
Attendees by telephone: Kevin Coulores (Yale), Matt Braga (Dartmouth), Kim Marohn
(Baystate), Jonathan Wood (EMMC), Aaron Zucker (CCMC), Rebecca Bell (UVM)
1.
Pre-meeting informal discussion of Massive Transfusion Protocol- UMass
and Baystate providers had previously collaborated on initial steps. UMass has
completed their protocol and presented it to the group. Protocol presents products
and volumes to be delivered, time frames for notification and delivery of products
and responsibilities of the various providers including both ED/ ICU team as well
as blood bank members.
Since implementation of the policy there have been 2 activations- blood bank
fellow comes to bedside and assists with directing transfusion of products.
UMass not currently using TEG- brief discussion of use of TEG in children.
Some data available, but limited – not yet validated/ approved for use in children.
2.
Sedation and Analgesia practices- Dave Tiber (UMass)- presented comments
from a recent educational session which discussed “Novel Practices” including:
-inhaled nitrous oxide for IV placement
-J-tip to deliver SQ lidocaine.
-intranasal dexmedetomidine
Expense of nitrous discussed, and experience in other units with J-tip which was
variable.
-Carol Pineda (Tufts) notes they have started using nitrous
-Jonathan Wood (EMMC) notes they have not used nitrous due to logistics/
scavenging/ costs etc and what they have is working well without it.
-UMass NICU using chloral hydrate for PFTs- not used outside NICU. (due to
lack of interference with pulmonary function testing). No-one reports
consistently using intranasal versed.
-Several units (EMMC, UMass) seem to be providing sedation for nearly all
pediatric procedures including sites more remote (but still physically attached to
hospital) including office surgical/ onc procedures, etc.
-Space includes short stay pedi rooms in radiology and an inpatient sedation room
on pedi wards.
-UMass previously had sedation nurses, now using clinic nurses. Tufts also has
sedation nurses- many prior picu nurses.
-Sedation service run by intensivists At both UMass and EMMC , hospitalists
provide sedation as well as intensivists- but at UMass, hospitalists provide only
minimal to moderate sedation with ICU providing all deep sedation. At EMMC,
hospitalists also provide deep sedation but have rigorous training and QI program
before they can provide this.
-Tufts has recently started database to track outcomes/ complications. Sedation
nurses enter data, secretary enters demographic data. Can be used when a patient
returns for multiple procedures- able to easily access information from prior
sedations. This was felt to be potentially clinically helpful at multiple hospitalsbut personnel to input and maintain database would be limiting step.
-Jonathan offered that Maine and Yale were previously in a consortium to track
sedation data (2003, led by Joe Carrera). Jonathan to add info about
consortium to NEPICC website.
-UMass still having issues with lack of compensation by various insurance
providers despite being anesthesia credentialed. EMMC has built their hospitalist
program from the sedation reimbursement, including child life support. (approx.
800 cases/ year)
-Discussion of using simulation to model adverse events during sedations (eg how
to extricate from MRI to manage an airway etc)- activating RRT etc. This type of
crisis resource training was felt to be valuable by all, but once again resources at
various institutions were limiting. ( In situ vs sim lab simulations, high fidelity
mannequins, staff for simulation training). Kevin Coulores from Yale to share
their simulation curriculum for mock RRT response.
3.
Billing Issues – in general and related to post op care- Matt Braga
(Dartmouth). – Matt reports that in frequently patients who will be admitted post
op are sent to PICU/ stepdown for recovery rather than PACU. He has been
questioned by compliance about billing for Critical Care Time (CCT) for this
period, as the recovery monitoring period is considered part of the OR time and is
bundled with OR payment.
-Chris McKiernan (Baystate) reports that at critical care meetings which include
the adult services this is becoming an increasing issue as the entire admission fee
is “bundled” and ICU billing and fees are considered part of the overall cost to be
managed/ distributed by the hospital system. (eg. total hip fee now includes from
OR to rehab, single payment for some insurers regardless of pt’s post op course).
This is not yet common in pediatrics, but may be in the future.
-Variable practices around CCT billing at our various institutions. Many report
the first day is nearly always CCT with step down from there as clinically
appropriate. Need for consistency between providers, particularly day to day
billing as that will raise red flags to insurers. UMass being internally audited in
near future- will report back at next meeting.
-This discussion also raised discussion of “favorite” or most common diagnoses
for billing- including respiratory failure etc. – suggestion that each institution poll
billing for their top 20 diagnoses and compare practices between providers for
discussion amongst the group.
4.
Mission Statement- Jonathan Wood and Sholeen Nett- Jonathan offered a
mission statement listing the goals of the group. We discussed vision statement
(who we want to be in the future) vs. mission statement (what we want to do now)
and how detailed vs succinct these should be. Overall the first draft was felt to be
too detailed. Jonathan to re-wordsmith with Sholeen and post newer version
on website to invite comments and discussion.
5.
Level 1 vs Level 2 PICU- Scot Bateman (UMass)- - article presented (attached)
(Rosenberg, CCM 2004) with definitions and requirements for levels. Bias is
clearly from larger centers. Question raised if we should redefine from group
such as NEPICC? Discussion around why to define and what is benefit/ risk of
defining.
-Matt Braga noted it was helpful for him to have minimum requirements to
advocate for needs as Dartmouth PICU redefined. Felt this may be helpful to
others as well as financial pressures increase.
-After some discussion, consensus was that none of our units are currently in
jeopardy from this 12 year old definition. Risk of backfire if we try to make a
statement about levels. Group felt it was better to demonstrate excellent care/
quality metrics than to define level 1 or 2 requirements.
-Question was raised if a new definition was in process by other group(s)- no-one
aware of such an effort currently. Question if we are being undervalued regionally
or nationally because of this definition. Scot to create group who will better
define who we are and what we need to function, standard or quality of care
that needs to be maintained to be PICU.
6.
Database of transfers out- (Scot Bateman, UMass)- stemming from the
discussion above, we discussed reasons that patients are transferred out from our
PICUs to other institutions. Felt it would be interesting to track a group database
to better understand what we can and cannot provide, what our resources are, why
and when transfers are made.
-Deciding when to transfer a patient remains a very difficult decision for PICU’s
without full services. Can an evaluation of our transfer patients provide any
insight in how to direct pediatric intensivists on transfer decisions?
-Would need to have consistent severity scoring (PRISM). May help develop
guidelines for patient transfer. This was felt to be an opportunity for collaborative
research. Lauren Fortier (UMass) to develop and circulate a brief
questionnaire to group to assess reasons for transfer.
7.
PICU Prophylaxis- (various members) –
GI prophylaxis- varies by attending- Steffi Gauguet (UMass) discussed newer
studies- no clear data in adults- are we altering the microbiome for the worse?
Don’t really know
No consensus from group about this practice.
-Insulin/ Euglycemia- DSMB stopped half-pint study (tight glycemic control
randomized study in picu patients) due to lack of benefit.
-DVT prophylaxis- some use Cincinnati Children’s criteria
Age >18yo as adults
-VAP- standard VAP order sets/ care
-CAUTI- peri care, empowering nurses. Baystate has policy allowing nurses to
pull foley’s
-No PICU from our group currently employing whole body/ patient bathing with
chlorhexidine baths
-Rebecca Bell noted many of these bundles and resources available on Solutions
for Patient Safety website. Over 100 member institutions, but guidelines free and
available to all regardless of membership. She will post a link to this on email
and to our NEPICC website.