Browsing by Author "Malin, Stefan W."

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    A Quality Improvement Initiative to Reduce Unnecessary Screening Chest Radiographs in a Pediatric ICU
    (American Association of Respiratory Care, 2023) Malin, Stefan W.; Maue, Danielle K.; Cater, Daniel T.; Ealy, Aimee R.; McCallister, Anne E.; Valentine, Kevin M.; Abu-Sultaneh, Samer M.; Pediatrics, School of Medicine
    Background: The Critical Care Societies Collaborative included not ordering diagnostic tests at regular intervals as one of their Choosing Wisely initiatives. A reduction in unnecessary chest radiographs (CXRs) can help reduce exposure to radiation and eliminate health care waste. We aimed to reduce daily screening CXRs in a pediatric ICU (PICU) by 20% from baseline within 4 months of implementation of CXR criteria. Methods: All intubated patients in the PICU were included in this quality improvement project. Patients with tracheostomies were excluded. We developed criteria delineating which patients were most likely to benefit from a daily screening CXR, and these criteria were discussed for each patient on rounds. Patients on extracorporeal membrane oxygenation, on high-frequency oscillatory ventilation, or on high support on conventional mechanical ventilation were included as needing a daily screening CXR. We tracked the percentage of intubated subjects receiving a screening CXR as an outcome measure. Unplanned extubations and the number of non-screening CXRs per intubated subject were followed as balancing measures. Results: The percentage of intubated subjects receiving a daily screening CXR was reduced from 79% to 31%. There was no increase in frequency of unplanned extubations or number of non-screening CXRs. With an estimated subject charge of roughly $270 and hospital cost of $54 per CXR, this project led to an estimated $300,000 in patient charge savings and $60,000 in hospital cost savings. Conclusions: Adopting criteria to delineate which patients are most likely to benefit from screening CXRs can lead to a reduction in the percentage of intubated patients receiving screening CXRs without appearing to increase harm.
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    A Quality Improvement Initiative to Reduce Unneeded Screening Chest Radiographs in a Pediatric Cardiovascular ICU
    (Daedalus Enterprises, 2023) Malin, Stefan W.; McCallister, Anne E.; Abu-Sultaneh, Samer M.; Valentine, Kevin M.; Pediatrics, School of Medicine
    Background: Adult critical care and radiographical societies have recommended changing practice from routine screening radiographs to on-demand chest radiographs (CXRs) for stable mechanically ventilated adult patients. There are no similar recommendations for patients in the pediatric ICU. Reducing the frequency with which unneeded CXRs are obtained can decrease radiation exposure and reduce waste, a substantial contributor to rising health care costs. We aimed to reduce unneeded daily screening CXRs in a pediatric cardiovascular ICU (CICU) by 20% in 6 months. Methods: Criteria delineating which subjects in the CICU required daily screening CXRs were created and added to the daily rounding sheet for discussion for each subject. The primary goal of this study was to reduce CXRs in mechanically ventilated subjects as our previous practice had been to order daily CXRs. Respiratory therapists increased the frequency of evaluating and documenting endotracheal tube positioning prior to the initiation of this project. The outcome measure was the percentage subjects who received a daily screening CXR. The ratio of daily screening CXRs to the number of total CXRs ordered and unplanned extubations were followed as balancing measures. Results: The number of subjects who received a daily screening CXR decreased from a baseline of 67% to 44% over the course of this project. There was no change in the ratio of daily screening CXRs to the number of total CXRs ordered or an increase in unplanned extubations. With an estimated cost of $268 per CXR, a reduction of 33% in routine screening CXRs saves an estimated $250,000 annually. Conclusions: A decrease in daily screening CXRs can be sustained through the development of specific criteria to determine which patients need screening radiographs. This can be achieved without an increase in CXRs obtained at other times throughout the day or an increase in unplanned extubations. This eliminates unneeded health care expenditures, improves resource allocation for radiology technicians, and decreases disruptive interventions for patients.
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    Food Protein-Induced Enterocolitis Syndrome Causing Hypovolemic Shock and Methemoglobinemia
    (Hindawi, 2018-04-30) Malin, Stefan W.; Lutfi, Riad; Friedman, Matthew L.; Teagarden, Alicia M.; Pediatrics, School of Medicine
    A 5-week-old previously healthy male presented with vomiting and diarrhea leading to hypovolemic shock and profound metabolic acidosis. He was subsequently found to have severe methemoglobinemia. The acidosis and shock improved with fluid resuscitation and methemoglobinemia was successfully treated with methylene blue. An extensive workup, including evaluations for infectious and metabolic etiologies, was unremarkable. However, a detailed dietary history revealed a recent change in diet, supporting a diagnosis of food protein-induced enterocolitis syndrome (FPIES). We present this case to highlight the importance of considering FPIES in an infant with vomiting and diarrhea, in the setting of a recent dietary change, leading to profound dehydration, metabolic acidosis, and methemoglobinemia. Diagnosis of FPIES, although difficult to make and one of exclusion, can be potentially life-saving.