Spotlight Case March 2011

1. Spotlight Case March 2011 Volume Too Low: In and Out Pediatric Patient Safety

2. Source and Credits • This presentation is based on the March 2011AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Marlene Miller, MD, MSc, Johns Hopkins Children's Center • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Appreciate that because of multiple factors, children are at high risk for medical errors. • Describe the importance of weight-based dosing of medications and fluids in pediatrics. • Describe how the inability to communicate clearly can place pediatric patients at risk for medical errors or unsafe care. • List 2 interventions that may help providers more safely care for pediatric patients.

4. Case: Pediatric Patient Safety (1) A 22-month-old infant was admitted to the hospital in the late afternoon with a viral infection. He had a complex past medical history including congenital heart disease, poor feeding requiring a gastric tube, and delayed cognitive development. At the time of admission, he was moderately ill appearing but remained interactive with his mother and hospital staff. He was given appropriate therapies for his viral infection.

5. Case: Pediatric Patient Safety (2) Later in the evening, the infant drank 2 ounces (60 mL) of a liquid nutritional drink and then went to sleep; this was the sum total of his fluid consumption since hospital admission. The child slept well and in the morning his vital signs were all normal. He remained interactive but seemed a bit sleepy.

6. Case: Pediatric Patient Safety (3) His total urine output overnight as documented by the nurse was 50 mL (a low urine output given his weight of 10 kg). The night nurse communicated the minimal intake of fluids and poor urine output to the day nurse at the 7:00 AM change of shift.

7. Case: Pediatric Patient Safety (4) The day nurse, busy caring for other patients, failed to appreciate the significance of the low intake and output. Over the next few hours, the infant became more somnolent and less responsive. His aunt assumed this was due to the viral infection, and the child was not evaluated by the nurse during this time. When his mother returned in the early afternoon, she found her son to be lethargic and acting strangely.

8. Case: Pediatric Patient Safety (5) Evaluation by the intern revealed a low blood pressure, high heart rate, decreased muscle tone, and decreased responsiveness to stimulation. Stat labs revealed severe hypoglycemia and dehydration. The infant was transferred to the pediatric intensive care unit where an IV was placed, and he was given intravenous fluids and intravenous glucose. He required 2 days in the intensive care unit but did not experience any long-term consequences.

9. Children and Medical Errors • Multiple characteristics increase risk of medical errors or adverse events in children • Physical characteristics • Example: miscalculation of medication dosing • Developmental issues • Example: an infant is unable to ask a provider to wash his or her hands • Minor legal status issues • Example: obtaining consent for procedures from children and/or their parents See Notes for reference.

10. Risks in Hospitalized Children • Two major hazards place hospitalized children at risk: • The need to quantify therapies and assessments based on weight • The inability of children to communicate clearly with health care providers See Notes for reference.

11. Dosing in Adults • Doses of common medications in adults are generally recognizable and do not need specific calculations • Pain medications, antibiotics • Most adults can receive standard doses of medications without changes based on weight • Weight variation in adults from lightest to heaviest is at most 6-7x

12. Pediatric Dosing and Assessments • In children, the weight variation from lightest to heaviest may be as much as 450x! • Newborn in the neonatal ICU: 250 g • Overweight adolescent: 114 kg (114,000 g) • Given weight variation, providers cannot rely on intuitive sense or prior experience of “right dose” • All treatments (e.g., medications) and assessments (e.g., fluid intake/output) must be based on weight

13. Medication Errors in Pediatrics • Errors in prescribing, dispensing, and administering medications • Children at much greater risk for medication errors than adults • As almost all aspects of pediatric medication management are age and/or weight based, errors are common See Notes for references.

14. Fluid Requirements in Pediatrics • Fluids given to children and their urine output are weight-dependent and change with age • There are clearly defined standard fluid requirements • 4mL/kg body weight/hour for the first 10 kg • 2mL/kg body weight/hour for the second 10 kg • 1mL/kg body weight/hour for each kg past 20 kg See Notes for reference.

15. Example Calculation • Standard fluid requirement for a 25 kg child would be 65 mL per hour. • 4 mL/kg/hr x 10 kg = 40 mL/hr for first 10kg • 2 mL/kg/hr x 10 kg = 20 mL/hr for second 10kg • 1 mL/kg/hr x 5 kg = 5 mL/hr for last 5kg • Total = 40 mL/hr + 20 mL/hr + 5 mL/hr = 65 mL/hr

16. This Child’s Fluid Intake • This child’s weight was 10kg, translating into a fluid requirement of 40 mL/hr or 960 mL/day • 4 mL/kg/hr x 10 kg x 24 hr = 960 mL/day • He only consumed 2 ounces (60mL) of a nutritional drink • This fluid deficit of 900 mL led to his severe dehydration

17. This Child’s Urine Output • Abnormally low urine output for an infant (< 1 year) is < 1 mL/kg body weight/hour • Abnormally low urine output for a child (> 1 year) is < 5 mL/kg body weight/hour • This child had 50 mL in 12 hours, equivalent to 0.2 mL/kg/hr • This is substantially below expected urine output and was abnormal See Notes for reference.

18. Problems with Communication • Children at risk because of inability to clearly communicate • Children or those with developmental delay may be unable to communicate problems clearly • Unable to communicate: “I am thirsty” or “I have pain” • Pediatric patients may not be able to ask questions or advocate for themselves • May not ask why they are taking a new medication • Cannot make sure providers are working under sterile conditions

19. Problems with Communication (2) • Parents or guardians often advocate for their children and ask questions on their behalf • Yet parents or guardians may need to leave the bedside of their children (for self care, other responsibilities) • Children then depend on medical staff for protection from errors or adverse events

20. Congenital Heart Disease • This child also had congenital heart disease which is associated with specific risks • Many children with congenital heart disease cannot easily tolerate even small degrees of dehydration • Because of decreased cardiac function or shunting of blood, dehydration can lead to worsening cardiac function • Providers here likely should have been more vigilant about fluid intake and output given the underlying congenital heart disease

21. Preventing Errors in Pediatrics • All therapies and fluid assessments should be quantitatively done and recorded using appropriate weight-based algorithms • Standardized recording here may have led to recognition of low intake and low output

22. Preventing Medication Errors • Computerized daily input and output management might help recognize abnormal values • Computerized order entry may help guide physicians with weight-based prescribing

23. Assessing Pediatric Status • Pediatric early warning systems (PEWS) or rapid response teams could have potentially prevented the error in this case • PEWS routinely monitor behavior, cardiovascular, and respiratory status in hospitalized children

24. Sample PEWS Card See Notes for definitions.

25. Pediatric Early Warning Systems • The goal is to identify clinical declines earlier • A child is considered at risk if score is ≥ 4 points total or ≥ 3 points in any of the three main domains • One study reported a > 11 hr forewarning of decline • A different study showed a PEWS could identify 87% of children who were “at risk” for clinical deterioration See Notes for references.

26. Pediatric Rapid Response Teams • Rapid response teams can prevent worsening illness • A pediatric rapid response team here may have identified poor perfusion from dehydration earlier and provided fluids sooner See Notes for references.

27. Take-Home Points • Many aspects of the care of children require age and/or weight-based considerations to understand what is ‘normal’ for children. These aspects include almost all medication dosing, nutrition management, fluid intake, fluid outputs, and even equipment sizes. • Providers of care for children need to be well versed in these age/weight considerations.

28. Take-Home Points (2) • Children with congenital heart disease are at risk of dehydration and providers should be vigilant about fluid status. • Tools to assist in managing children, such as computerized bedside management systems (that can both create orders as well as track fluids and output) and early warning score cards can aid in the appropriate and safe care of children.