Browsing by UMass Chan Affiliation "University of Massachusetts Memorial Children's Medical Center"
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Improving Efficiency and Communication around Sedated Fracture Reductions in a Pediatric Emergency DepartmentIntroduction: Procedural sedation for fracture reduction in the pediatric emergency department (ED) is a time-consuming process requiring multidisciplinary coordination. We implemented a quality improvement initiative aimed at (1) decreasing mean ED length of stay (LOS) for children with sedated long bone fracture reductions by 15% over 12 months and (2) improving interdisciplinary communication around procedural sedation. Methods: Pediatric emergency medicine fellows at a children's hospital designed and implemented an initiative targeting the efficiency of the sedation process. Interventions included a centralized sedation tracking board, a team member responsibility checklist, family handouts, early discharge initiatives, and postsedation review forms. We tracked progress via statistical process control charts and interdisciplinary communication by intermittent surveys. Results: Pediatric emergency medicine fellows performed 2,246 sedations during the study period. Mean LOS decreased from 361 to 340 minutes (5.8%) after implementation and demonstrated sustainability over the postintervention period. One hundred eight providers completed the preimplementation communication survey, with 58 and 64 completing surveys at 4 and 9 months postimplementation, respectively. The proportion reporting somewhat or strong satisfaction with communication increased from 68% at baseline to 86% at 4 months (P = 0.02) and 92% at 9 months (P < 0.001 versus baseline). Conclusions: A quality improvement initiative created a sustainable process to reduce ED LOS for sedated reductions while improving satisfaction with interdisciplinary communication.
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Lithium-Induced Chronic Kidney Disease in a Pediatric PatientLithium-induced nephropathy usually manifests in adulthood as it develops slowly after many years of cumulative exposure. There is very limited information available in pediatric patients. Renal function monitoring and timely intervention is the key in preventing lithium-induced chronic kidney disease in these patients. We report a case of a 14-year-old boy who was on lithium for almost 9 years for his complex psychiatric illness. He presented with increased urinary frequency and nocturia. His serum creatinine increased to 1.15 mg/dL (estimated glomerular filtration rate or eGFR 53 ml/min/1.73 m(2)) from a baseline of 0.78 mg/dL (eGFR 86 ml/min/1.73 m(2)) a year prior to this presentation. Results of the imaging study were consistent with lithium-induced nephropathy. He was managed conservatively. His serum creatinine returned to baseline of 0.78 mg/dL after a year of discontinuation of lithium, consistent with mild chronic kidney disease. This case highlights the fact that lithium-induced chronic kidney disease can present in pediatric age group when lithium is initiated at a young age in children and that timely intervention may prevent further progression of renal damage. In addition to drug levels, routine monitoring of renal function during lithium therapy is essential.
