Development of a Standardized Clinical Assessment and Management Plan for Pediatric Acute Respiratory Distress Syndrome

Abstract

Pediatric acute respiratory distress syndrome (PARDS) is one of the most challenging patient populations for a clinician to manage with mortality between 8 and 31%. The project was designed to identify patients with PARDS, implement management guidelines with the goal of standardizing practice. Our objectives were to describe the development and implementation of a protocolized approach to identify patients with PARDS and institute ventilator management guidelines. Patients who met criteria for moderate or severe PARDS as per the Pediatric Acute Lung Injury Consensus Conference (PALICC) definitions were identified using the best practice alert (BPA) in the electronic health record (EHR). Patients who did not meet exclusion criteria qualified for management using the Standardized Clinical Assessment and Management Plan (SCAMP), a quality improvement (QI) methodology with iterative cycles. The creation of a BPA enabled identification of patients with PARDS. With our second cycle, the number of false BPA alerts due to incorrect data decreased from 66.7 (68/102) to 29.2% (19/65; p < 0.001) and enrollment increased from 48.3 (14/29) to 73.2% (30/41; p = 0.03). Evaluation of our statistical process control chart (SPC) demonstrated a shift in the adherence with the tidal volume guideline. Overall, we found that SCAMP methodology, when used in the development of institutional PARDS management guidelines, allows for development of a process to aid identification of patients and monitor adherence to management guidelines. This should eventually allow assessment of impact of deviations from clinical practice guidelines.

Keywords: clinical decision support tools; pediatric acute respiratory distress syndrome; quality improvement methodology; standardized clinical assessment and management plan.

Fig. 1

Run chart demonstrating percentage of false BPA alerts. Arrow points to time of implementation of second cycle.

Fig. 2

Stacked bar chart demonstrating the pareto analysis of reasons for false BPA alerts. Second cycle implemented on 10/2018.

Fig. 3

Statistical process control chart ( p -type) demonstrating adherence with TV titration. Arrow points to time of implementation of second cycle. UCL – upper control limit, LCL – lower control limit.

Fig. 4

Statistical process control chart ( p -type) demonstrating adherence with PEEP/FiO ₂ titration. Arrow points to time of implementation of second cycle. UCL – upper control limit, LCL – lower control limit.