nutch_noindex
CANCEL
COVID-2019 Alert

The latest information about the 2019 Novel Coronavirus, including vaccine clinics for children ages 5 years old and older.

La información más reciente sobre el nuevo Coronavirus de 2019, incluidas las clínicas de vacunación para niños de 5 años en adelante.

/nutch_noindex

Katherine Steffen, MD

  • Katherine Marie Steffen

Specialties

Critical Care Medicine

Work and Education

Professional Education

University of Iowa Carver College of Medicine, Iowa City, IA, 5/16/2008

Residency

Johns Hopkins Childrens Center, Baltimore, MD, 6/30/2011

Fellowship

Johns Hopkins University Pediatric Critical Care Fellowship, Baltimore, MD, 6/30/2014

Board Certifications

Pediatric Critical Care Medicine, American Board of Pediatrics

Pediatrics, American Board of Pediatrics

All Publications

What Laboratory Tests and Physiologic Triggers Should Guide the Decision to Administer a Platelet or Plasma Transfusion in Critically Ill Children and What Product Attributes Are Optimal to Guide Specific Product Selection? From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Delaney, M., Karam, O., Lieberman, L., Steffen, K., Muszynski, J. A., Goel, R., Bateman, S. T., Parker, R. I., Nellis, M. E., Remy, K. E., Pediatric Critical Care Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding (TAXI-CAB), i. c. 1800; 23 (Supplement 1 1S): e1-e13

Abstract

OBJECTIVES: To present consensus statements and supporting literature for plasma and platelet product variables and related laboratory testing for transfusions in general critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.DESIGN: Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.SETTING: Not applicable.PATIENTS: Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: A panel of 10 experts developed evidence-based and, when evidence was insufficient, expert-based statements for laboratory testing and blood product attributes for platelet and plasma transfusions. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative - Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed five expert consensus statements and two recommendations in answer to two questions: what laboratory tests and physiologic triggers should guide the decision to administer a platelet or plasma transfusion in critically ill children; and what product attributes are optimal to guide specific product selection?CONCLUSIONS: The Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program provides some guidance and expert consensus for the laboratory and blood product attributes used for decision-making for plasma and platelet transfusions in critically ill pediatric patients.

View details for DOI 10.1097/PCC.0000000000002854

View details for PubMedID 34989701

Plasma and Platelet Transfusion Strategies in Critically Ill Children With Malignancy, Acute Liver Failure and/or Liver Transplantation, or Sepsis: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Lieberman, L., Karam, O., Stanworth, S. J., Goobie, S. M., Crighton, G., Goel, R., Lacroix, J., Nellis, M. E., Parker, R. I., Steffen, K., Stricker, P., Valentine, S. L., Steiner, M. E., Pediatric Critical Care Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding (TAXI-CAB), i. c. 1800; 23 (Supplement 1 1S): e37-e49

Abstract

OBJECTIVES: To present the consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.DESIGN: Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.SETTING: Not applicable.PATIENTS: Critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: A panel of 13 experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children with malignancy, acute liver disease and/or following liver transplantation, and sepsis and/or disseminated intravascular coagulation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 12 expert consensus statements.CONCLUSIONS: In the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding program, the current absence of evidence for use of plasma and/or platelet transfusion in critically ill children with malignancy, acute liver disease and/or following liver transplantation, and sepsis means that only expert consensus statements are possible for these areas of practice.

View details for DOI 10.1097/PCC.0000000000002857

View details for PubMedID 34989704

Executive Summary of Recommendations and Expert Consensus for Plasma and Platelet Transfusion Practice in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding (TAXI-CAB). Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Nellis, M. E., Karam, O., Valentine, S. L., Bateman, S. T., Remy, K. E., Lacroix, J., Cholette, J. M., Bembea, M. M., Russell, R. T., Steiner, M. E., Goobie, S. M., Tucci, M., Stricker, P. A., Stanworth, S. J., Delaney, M., Lieberman, L., Muszynski, J. A., Bauer, D. F., Steffen, K., Nishijima, D., Ibla, J., Emani, S., Vogel, A. M., Haas, T., Goel, R., Crighton, G., Delgado, D., Demetres, M., Parker, R. I., Pediatric Critical Care Transfusion and Anemia EXpertise InitiativeControl/Avoidance of Bleeding (TAXI-CAB), i. c. 1800; 23 (1): 34-51

Abstract

OBJECTIVES: Critically ill children frequently receive plasma and platelet transfusions. We sought to determine evidence-based recommendations, and when evidence was insufficient, we developed expert-based consensus statements about decision-making for plasma and platelet transfusions in critically ill pediatric patients.DESIGN: Systematic review and consensus conference series involving multidisciplinary international experts in hemostasis, and plasma/platelet transfusion in critically ill infants and children (Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding [TAXI-CAB]).SETTING: Not applicable.PATIENTS: Children admitted to a PICU at risk of bleeding and receipt of plasma and/or platelet transfusions.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: A panel of 29 experts in methodology, transfusion, and implementation science from five countries and nine pediatric subspecialties completed a systematic review and participated in a virtual consensus conference series to develop recommendations. The search included MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020, using a combination of subject heading terms and text words for concepts of plasma and platelet transfusion in critically ill children. Four graded recommendations and 49 consensus expert statements were developed using modified Research and Development/UCLA and Grading of Recommendations, Assessment, Development, and Evaluation methodology. We focused on eight subpopulations of critical illness (1, severe trauma, intracranial hemorrhage, or traumatic brain injury; 2, cardiopulmonary bypass surgery; 3, extracorporeal membrane oxygenation; 4, oncologic diagnosis or hematopoietic stem cell transplantation; 5, acute liver failure or liver transplantation; 6, noncardiac surgery; 7, invasive procedures outside the operating room; 8, sepsis and/or disseminated intravascular coagulation) as well as laboratory assays and selection/processing of plasma and platelet components. In total, we came to consensus on four recommendations, five good practice statements, and 44 consensus-based statements. These results were further developed into consensus-based clinical decision trees for plasma and platelet transfusion in critically ill pediatric patients.CONCLUSIONS: The TAXI-CAB program provides expert-based consensus for pediatric intensivists for the administration of plasma and/or platelet transfusions in critically ill pediatric patients. There is a pressing need for primary research to provide more evidence to guide practitioners.

View details for DOI 10.1097/PCC.0000000000002851

View details for PubMedID 34989711

Ultrasound education improves safety for peripheral intravenous catheter insertion in critically ill children. Pediatric research Bhargava, V., Su, E., Haileselassie, B., Davis, D., Steffen, K. M. 2021

Abstract

BACKGROUND: Difficulty in obtaining peripheral vascular access is a common problem in patients admitted to the pediatric intensive care unit (PICU). The use of ultrasound guidance can improve the overall success in obtaining vascular access. This study evaluated the success and longevity of PIV placement by nurses pre- and post-implementation of an USGPIV curriculum.METHODS: PICU nurses participated in a prospective quality improvement study. Each participating nurse attempted 10 PIVs by using landmark (LM) methods. The same nurses then received individual instruction in an USGPIV placement curriculum. Following the educational intervention, each nurse attempted 10 USGPIVs.RESULTS: A total of 150 LM PIVs and 143 USGPIVs were attempted. The first stick success in the post-intervention (USGPIV) group was 85.9% compared to 47.3% in the pre-intervention (LM) group (p<0.001). Overall success was also superior in the USGPIV group (94.3 versus 57.3%, respectively; p<0.001). PIVs placed by US lasted longer with a median survival time of 43.84 daysversus 33.51 days for LM PIVs (p<0.050, log-rank test).CONCLUSIONS: Successful implementation of a standardized curriculum for USGPIV placement for PICU nurses improves first stick, overall success, and longevity of PIV catheter placement.IMPACT: An ultrasound-guided IV curriculum can be successfully implemented resulting in increased first stick success and increased longevity. Registered nurses can be trained in placement of ultrasound-guided IV placement. This study provides a training curriculum for ultrasound-guided IV placement that can be applied to other settings or institutions.

View details for DOI 10.1038/s41390-021-01568-6

View details for PubMedID 34075190

Implementation of clinical practice changes in the PICU: a qualitative study using and refining the iPARIHS framework. Implementation science : IS Steffen, K. M., Holdsworth, L. M., Ford, M. A., Lee, G. M., Asch, S. M., Proctor, E. K. 2021; 16 (1): 15

Abstract

Like in many settings, implementation of evidence-based practices often fall short in pediatric intensive care units (PICU). Very few prior studies have applied implementation science frameworks to understand how best to improve practices in this unique environment. We used the relatively new integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to assess practice improvement in the PICU and to explore the utility of the framework itself for that purpose.We used the iPARIHS framework to guide development of a semi-structured interview tool to examine barriers, facilitators, and the process of change in the PICU. A framework approach to qualitative analysis, developed around iPARIHS constructs and subconstructs, helped identify patterns and themes in provider interviews. We assessed the utility of iPARIHS to inform PICU practice change.Fifty multi-professional providers working in 8U.S. PICUs completed interviews. iPARIHS constructs shaped the development of a process model for change that consisted of phases that include planning, a decision to adopt change, implementation and facilitation, and sustainability; the PICU environment shaped each phase. Large, complex multi-professional teams, and high-stakes work at near-capacity impaired receptivity to change. While the unit leaders made decisions to pursue change, providers' willingness to accept change was based on the evidence for the change, and provider's experiences, beliefs, and capacity to integrate change into a demanding workflow. Limited analytic structures and resources frustrated attempts to monitor changes' impacts. Variable provider engagement, time allocated to work on changes, and limited collaboration impacted facilitation. iPARIHS constructs were useful in exploring implementation; however, we identified inter-relation of subconstructs, unique concepts not captured by the framework, and a need for subconstructs to further describe facilitation.The PICU environment significantly shaped the implementation. The described process model for implementation may be useful to guide efforts to integrate changes and select implementation strategies. iPARIHS was adequate to identify barriers and facilitators of change; however, further elaboration of subconstructs for facilitation would be helpful to operationalize the framework.Not applicable, as no health care intervention was performed.

View details for DOI 10.1186/s13012-021-01080-9

View details for PubMedID 33509190

Factors Influencing Implementation of Blood Transfusion Recommendations in Pediatric Critical Care Units. Frontiers in pediatrics Steffen, K. M., Spinella, P. C., Holdsworth, L. M., Ford, M. A., Lee, G. M., Asch, S. M., Proctor, E. K., Doctor, A. 1800; 9: 800461

Abstract

Purpose: Risks of red blood cell transfusion may outweigh benefits for many patients in Pediatric Intensive Care Units (PICUs). The Transfusion and Anemia eXpertise Initiative (TAXI) recommendations seek to limit unnecessary and potentially harmful transfusions, but use has been variable. We sought to identify barriers and facilitators to using the TAXI recommendations to inform implementation efforts. Materials and Methods: The integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework guided semi-structured interviews conducted in 8 U.S. ICUs; 50 providers in multiple ICU roles completed interviews. Adapted Framework analysis, a form of content analysis, used the iPARIHS innovation, recipient, context and facilitation constructs and subconstructs to categorize data and identify patterns as well as unique informative statements. Results: Providers perceived that the TAXI recommendations would reduce transfusion rates and practice variability, but adoption faced challenges posed by attitudes around transfusion and care in busy and complex units. Development of widespread buy-in and inclusion in implementation, integration into workflow, designating committed champions, and monitoring outcomes data were expected to enhance implementation. Conclusions: Targeted activities to create buy-in, educate, and plan for use are necessary for TAXI implementation. Recognition of contextual challenges posed by the PICU environment and an approach that adjusts for barriers may optimize adoption.

View details for DOI 10.3389/fped.2021.800461

View details for PubMedID 34976903

Target Based Care: An Intervention to Reduce Variation in Postoperative Length of Stay. The Journal of pediatrics Shin, A. Y., Rao, I. J., Bassett, H. K., Chadwick, W., Kim, J., Kipps, A. K., Komra, K., Loh, L., Maeda, K., Mafla, M., Presnell, L., Sharek, P. J., Steffen, K. M., Scheinker, D., Algaze, C. A. 2020

Abstract

OBJECTIVES: To derive care targets and evaluate the impact of displaying them at the point of care on postoperative length of stay (LOS).STUDY DESIGN: A prospective cohort study using 2 years of historical controls within a freestanding, academic children's hospital. Patients undergoing benchmark cardiac surgery between May 4, 2014 and August 15, 2016 (preintervention) and September 6, 2016 to September 30, 2018 (postintervention) were included. The intervention consisted of displaying at the point of care targets for the timing of extubation, transfer from the intensive care unit (ICU), and hospital discharge. Family satisfaction, reintubation, and readmission rates were tracked.RESULTS: The postintervention cohort consisted of 219 consecutive patients. There was a reduction in variation for ICU (difference in SD -2.56, p < 0.01), and total LOS (difference in SD -2.84, P < .001). Patients stayed on average 0.97 fewer days (p<0.001) in the ICU (median -1.01 [IQR -2.15,-0.39], 0.7 fewer days (p<0.001) on mechanical ventilation (median -0.54 [IQR -0.77,-0.50], and 1.18 fewer days (p<0.001) for the total LOS (median -2.25 [IQR -3.69,-0.15]. Log transformed multivariable linear regression demonstrated the intervention to be associated with shorter ICU LOS (beta coefficient -0.19, SE 0.059, p<0.001), total postoperative LOS (beta coefficient -0.12, SE 0.052, p=0.02), and ventilator duration (beta coefficient -0.21, SE 0.048, p<0.001). Balancing metrics did not differ after the intervention.CONCLUSIONS: Target based care is a simple, novel intervention associated with reduced variation in LOS and absolute LOS across a diverse spectrum of complex cardiac surgeries.

View details for DOI 10.1016/j.jpeds.2020.09.017

View details for PubMedID 32920104

Regulating Critical Care Ultrasound, It Is All in the Interpretation. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Su, E. n., Soni, N. J., Blaivas, M. n., Bhargava, V. n., Steffen, K. n., Haileselassie, B. n. 2020

Abstract

Point-of-care ultrasound (POCUS) use is rapidly expanding as a practice in adult and pediatric critical care environments. In January 2020, the Joint Commission endorsed a statement from the Emergency Care Research Institute citing point-of-care ultrasound as a potential hazard to patients for reasons related to training and skill verification, oversight of use, and recordkeeping and accountability mechanisms for clinical use; however, no evidence was presented to support these concerns. Existing data on point-of-care ultrasound practices in pediatric critical care settings verify that point-of-care ultrasound use continues to increase, and contrary to the concerns raised, resources are becoming increasingly available for point-of-care ultrasound use. Many institutions have recognized a successful approach to addressing these concerns that can be achieved through multispecialty collaborations.

View details for DOI 10.1097/PCC.0000000000002600

View details for PubMedID 33060421

Pediatric Transport Triage: Development and Assessment of an Objective Tool to Guide Transport Planning. Pediatric emergency care Steffen, K. M., Noje, C. n., Costabile, P. M., Henderson, E. n., Hunt, E. A., Klein, B. L., McMillan, K. N. 2020; 36 (5): 24047

Abstract

We developed a Pediatric Transport Triage Tool (PT3) to objectively guide selection of team composition and transport mode, thereby standardizing transport planning. Previously, modified Pediatric Early Warning Score for transport has been used to assess illness severity but not to guide transport decision making.The PT3 was created for pediatric transport by combining objective evaluations of neurologic, cardiovascular, and respiratory systems with a systems-based medical condition list to identify diagnoses requiring expedited transport and/or advanced team composition not captured by neurologic, cardiovascular, and respiratory systems alone. A scoring algorithm was developed to guide transport planning. Transport data (mode, team composition, time to dispatch, patient disposition, and complications) were collected before and after PT3 implementation at a single tertiary care center over an 18-month period.We reviewed 2237 inbound pediatric transports. Transport mode, patient disposition, and dispatch time were unchanged over the study period. Fewer calls using a transport nurse were noted after PT3 implementation (33.9% vs 30%, P = 0.05), with a trend toward fewer rotor-wing transports and transports requiring physicians. The majority of users, regardless of experience level, reported improved transport standardization with the tool. Need to upgrade team composition or mode during transport was not different during the study period. No adverse patient safety events occurred with PT3 use.The PT3 represents an objective triage tool to reduce variability in transport planning. The PT3 decreased resource utilization and was not associated with adverse outcomes. Teams with dynamic staffing models, various experience levels, and multiple transport modes may benefit from this standardized assessment tool.

View details for DOI 10.1097/PEC.0000000000001641

View details for PubMedID 30461668

View details for PubMedCentralID PMC6526089

ULTRASOUND-GUIDED IV PROGRAM IMPROVES FIRST STICK SUCCESS AND LONGEVITY IN CRITICALLY ILL CHILDREN Bhargava, V., Su, E., Haileselassie, B., Davis, D., Steffen, K. LIPPINCOTT WILLIAMS & WILKINS. 2020
Ultrasound-Targeted Lung Recruitment: Process Improvement for Ventilating the Critically Ill Child PEDIATRIC CRITICAL CARE MEDICINE Su, E., Steffen, K. M. 2019; 20 (5): 49394
Development of a Structured Outcomes Assessment and Implementation Program in the Pediatric Intensive Care Unit AMERICAN JOURNAL OF MEDICAL QUALITY Steffen, K. M., Lin, J. C., Malone, S., Doctor, A., Hartman, M. E. 2019; 34 (1): 2329
LEVERAGING AGGREGATE DATA AT THE POINT OF CARE REDUCES VARIATION FOR PEDIATRIC NEUROSURGERY PATIENTS Steffen, K., Su, F., Algaze, C., Duethman, L., Jacobs, K., Casazza, M., Chantra, J., Loh, L., Shin, A., Grant, G. LIPPINCOTT WILLIAMS & WILKINS. 2019
Use of Telemedicine During Interhospital Transport of Children With Operative Intracranial Hemorrhage* PEDIATRIC CRITICAL CARE MEDICINE Jackson, E. M., Costabile, P. M., Tekes, A., Steffen, K. M., Ahn, E. S., Scafidi, S., Noje, C. 2018; 19 (11): 103338

Abstract

To analyze the impact of an intervention of using telemedicine during interhospital transport on time to surgery in children with operative intracranial hemorrhage.We performed a retrospective chart review of children with intracranial hemorrhage transferred for emergent neurosurgical intervention between January 1, 2011 and December 31, 2016. We identified those patients whose neuroimaging was transmitted via telemedicine to the neurosurgical team prior to arrival at our center and then compared the telemedicine and nontelemedicine groups. Mann-Whitney U and Fisher exact tests were used to compare interval variables and categorical data.Single-center study performed at Johns Hopkins Hospital.Patients less than or equal to 18 years old transferred for operative intracranial hemorrhage.Pediatric transport implemented routine telemedicine use via departmental smart phones to facilitate transfer of information and imaging and reduce time to definitive care by having surgical services available when needed.Fifteen children (eight in telemedicine group; seven in nontelemedicine group) met inclusion criteria. Most had extraaxial hemorrhage (87.5% telemedicine group; 85.7% nontelemedicine group; p = 1.0), were intubated pre transport (62.5% telemedicine group; 71.4% nontelemedicine group; p = 1.0), and arrived at our center's trauma bay during night shift or weekend (87.5% telemedicine group; 57.1% nontelemedicine group; p = 0.28). Median trauma bay Glasgow Coma Scale scores did not differ (eight in telemedicine group; seven in nontelemedicine group; p = 0.24). Although nonsignificant, when compared with the nontelemedicine group, the telemedicine group had decreased rates of repeat preoperative neuroimaging (37.5% vs 57%; p = 0.62), shorter median times from trauma bay arrival to surgery (33min vs 47min; p = 0.22) and from diagnosis to surgery (146.5min vs 157min; p = 0.45), shorter intensive care stay (2.5 vs 5 d) and hospitalization (4 vs 5 d), and higher home discharge rates (87.5% vs 57.1%; p = 0.28).Telemedicine use during interhospital transport appears to expedite definitive care for children with intracranial hemorrhage requiring emergent neurosurgical intervention, which could contribute to improved patient outcomes.

View details for PubMedID 30134361

Implementation of the Recommendations for RBC Transfusions for Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies Steffen, K. M., Bateman, S. T., Valentine, S. L., Small, S., Spinella, P. C., Doctor, A., Pediatric Critical Care Transfusion and Anemia Initiative (TAXI), i. c. 2018; 19 (9S Suppl 1): S170S176

Abstract

OBJECTIVES: To provide context for the implementation of the Pediatric Critical Care Transfusion and Anemia Expertise Initiative recommendations for RBC transfusions including a review of prior research related to implementation of transfusion guidelines, efforts to facilitate implementation through Transfusion and Anemia Expertise Initiative, and to provide a framework for recommendation implementation.DESIGN: Review of existing clinical literature and description of a comprehensive approach to implementation based on Implementation Science principles.RESULTS: The Transfusion and Anemia Expertise Initiative recommendations on RBC transfusions are based on clinical evidence and aim to limit unnecessary and potentially harmful transfusions. Prior efforts to use transfusion guidelines include use of provider education, local guidelines, visual aids, prospective and retrospective audit and feedback as well as computerized decision support tools; however, no single approach has been identified as optimal for implementation in pediatric critical care settings. Evidence around provider beliefs and transfusion decision-making point to the need for additional provider education, emphasizing the importance of limiting transfusions, and the development of recommendations, such as the Transfusion and Anemia Expertise Initiative guidelines, that can be applied to specific clinical conditions.CONCLUSIONS: The Transfusion and Anemia Expertise Initiative guidelines will be broadly disseminated; however, coordinated implementation efforts will be required to impact practice. An approach that encourages involvement of a wide range of multiprofessional stakeholders, formal agreement on the implemented guidelines, selection of strategies that are practical and feasible, and active monitoring of clinical practice and outcomes throughout implementation is recommended. A formal second stage Transfusion and Anemia Expertise Initiative - Continuous Assessment of Blood-use is proposed to enhance implementation of the recommendations, follow uptake and impact on practice and patient outcomes, and ensure integration of new clinical evidence into the existing guideline as it is developed.

View details for PubMedID 30161073

Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative PEDIATRIC CRITICAL CARE MEDICINE Valentine, S. L., Bembea, M. M., Muszynski, J. A., Cholette, J. M., Doctor, A., Spinella, P. C., Steiner, M. E., Tucci, M., Hassan, N. E., Parker, R. I., Lacroix, J., Argent, A., Carson, J. L., Remy, K. E., Demaret, P., Emeriaud, G., Kneyber, M. J., Guzzetta, N., Hall, M. W., Macrae, D., Karam, O., Russell, R. T., Stricker, P. A., Vogel, A. M., Tasker, R. C., Turgeon, A. F., Schwartz, S. M., Willems, A., Josephson, C. D., Luban, N. C., Lehmann, L. E., Stanworth, S. J., Zantek, N. D., Bunchman, T. E., Cheifetz, I. M., Fortenberry, J. D., Delaney, M., van de Watering, L., Robinson, K. A., Malone, S., Steffen, K. M., Bateman, S. T., Pediat Critical Care Transfusion, Pediat Critical Care Blood Res, Pediat Acute Lung Injury Sepsis 2018; 19 (9): 88498

Abstract

To date, there are no published guidelines to direct RBC transfusion decision-making specifically for critically ill children. We present the recommendations from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.Consensus conference series of multidisciplinary, international experts in RBC transfusion management of critically ill children.Not applicable.None.Children with, or children at risk for, critical illness who receive or are at risk for receiving a RBC transfusion.A panel of 38 content and four methodology experts met over the course of 2 years to develop evidence-based, and when evidence lacking, expert consensus-based recommendations regarding decision-making for RBC transfusion management and research priorities for transfusion in critically ill children. The experts focused on nine specific populations of critically ill children: general, respiratory failure, nonhemorrhagic shock, nonlife-threatening bleeding or hemorrhagic shock, acute brain injury, acquired/congenital heart disease, sickle cell/oncology/transplant, extracorporeal membrane oxygenation/ventricular assist/ renal replacement support, and alternative processing. Data to formulate evidence-based and expert consensus recommendations were selected based on searches of PubMed, EMBASE, and Cochrane Library from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.The Transfusion and Anemia Expertise Initiative consensus conference developed and reached consensus on a total of 102 recommendations (57 clinical [20 evidence based, 37 expert consensus], 45 research recommendations). All final recommendations met agreement, defined a priori as greater than 80%. A decision tree to aid clinicians was created based on the clinical recommendations.The Transfusion and Anemia Expertise Initiative recommendations provide important clinical guidance and applicable tools to avoid unnecessary RBC transfusions. Research recommendations identify areas of focus for future investigation to improve outcomes and safety for RBC transfusion.

View details for PubMedID 30180125

View details for PubMedCentralID PMC6126913

Development of a Structured Outcomes Assessment and Implementation Program in the Pediatric Intensive Care Unit. American journal of medical quality : the official journal of the American College of Medical Quality Steffen, K. M., Lin, J. C., Malone, S., Doctor, A., Hartman, M. E. 2018: 1062860618788173

Abstract

This article reports on the Outcomes Program (OP) that the pediatric intensive care unit (PICU) developed to (1) monitor unit-based outcomes trends and safety data, (2) systematically identify targets for process improvement, and (3) implement new projects and care protocols with the aim of improving patient care. Following development of the OP structure in 2013, the authors have coordinated the components of outcomes data and reporting, clinical performance review, outcomes committee, knowledge translation, and implementation science programs to impact practice. Through routine provider updates, educational strategies, and prioritization of focused projects that include structured implementation plans, the model of PICU care has been improved. Described herein is the development of the process to evaluate intensive care unit outcomes and address the need for programmatic change through implementation science principles. Such a process may be of use in other PICUs.

View details for PubMedID 30009638

Assessment of Virtual Support of Cardiopulmonary Resuscitation Using a Checklist Chime, N. O., Jones, K., Steffen, K., Noje, C., Duval-Arnould, J., Hunt, E. A., McMillan, K. AMER ACAD PEDIATRICS. 2018
Tele-Pediatric Intensive Care for Critically Ill Children in Syria TELEMEDICINE AND E-HEALTH Ghbeis, M., Steffen, K. M., Braunlin, E. A., Beilman, G. J., Dahman, J., Ostwani, W., Steiner, M. E. 2017

Abstract

Armed conflicts can result in humanitarian crises and have major impacts on civilians, of whom children represent a significant proportion. Usual pediatric medical care is often disrupted and trauma resulting from war-related injuries is often devastating. High pediatric mortality rates are thus experienced in these ravaged medical environments.Using simple communication technology to provide real-time management recommendations from highly trained pediatric personnel can provide substantive clinical support and have a significant impact on pediatric morbidity and mortality.We implemented a "Tele-Pediatric Intensive Care" program (Tele-PICU) to provide real-time management consultation for critically ill and injured pediatric patients in Syria with intensive care needs.Over the course of 7 months, 19 cases were evaluated, ranging in age from 1 day to 11 years. Consultation questions addressed a wide range of critical care needs. Five patients are known to have survived, three were transferred, five died, and six outcomes were unknown.Based on this limited undertaking with its positive impact on survival, further development of Tele-PICU-based efforts with attention to implementation and barriers identified through this program is desirable.Even limited Tele-PICU can provide timely and potentially lifesaving assistance to pediatric care providers. Future efforts are encouraged.

View details for PubMedID 29232173

RBC Distribution Width: Biomarker for Red Cell Dysfunction and Critical Illness Outcome? PEDIATRIC CRITICAL CARE MEDICINE Said, A. S., Spinella, P. C., Hartman, M. E., Steffen, K. M., Jackups, R., Holubkov, R., Wallendorf, M., Doctor, A. 2017; 18 (2): 134-142

Abstract

RBC distribution width is reported to be an independent predictor of outcome in adults with a variety of conditions. We sought to determine if RBC distribution width is associated with morbidity or mortality in critically ill children.Retrospective observational study.Tertiary PICU.All admissions to St. Louis Children's Hospital PICU between January 1, 2005, and December 31, 2012.We collected demographics, laboratory values, hospitalization characteristics, and outcomes. We calculated the relative change in RBC distribution width from admission RBC distribution width to the highest RBC distribution width during the first 7 days of hospitalization. Our primary outcome was ICU mortality or use of extracorporeal membrane oxygenation as a composite. Secondary outcomes were ICU- and ventilator-free days.We identified 3,913 eligible subjects with an estimated mortality (by Pediatric Index of Mortality 2) of 2.94% 9.25% and an actual ICU mortality of 2.91%. For the study cohort, admission RBC distribution width was 14.12% 1.89% and relative change in RBC distribution width was 2.63% 6.23%. On univariate analysis, both admission RBC distribution width and relative change in RBC distribution width correlated with mortality or the use of extracorporeal membrane oxygenation (odds ratio, 1.19 [95% CI, 1.12-1.27] and odds ratio, 1.06 [95% CI, 1.04-1.08], respectively; p < 0.001). After adjusting for confounding variables, including severity of illness, both admission RBC distribution width (odds ratio, 1.13; 95% CI, 1.03-1.24) and relative change in RBC distribution width (odds ratio, 1.04; 95% CI, 1.01-1.07) remained independently associated with ICU mortality or the use of extracorporeal membrane oxygenation. Admission RBC distribution width and relative change in RBC distribution width both weakly correlated with fewer ICU- (r = 0.038) and ventilator-free days (r = 0.05) (p < 0.001).Independent of illness severity in critically ill children, admission RBC distribution width is associated with ICU mortality and morbidity. These data suggest that RBC distribution width may be a biomarker for RBC injury that is of sufficient magnitude to influence critical illness outcome, possibly via oxygen delivery impairment.

View details for DOI 10.1097/PCC.0000000000001017

View details for Web of Science ID 000394305600011

View details for PubMedID 27832023

View details for PubMedCentralID PMC5291765

Controlling Phlebotomy Volume Diminishes PICU Transfusion: Implementation Processes and Impact. Pediatrics Steffen, K. n., Doctor, A. n., Hoerr, J. n., Gill, J. n., Markham, C. n., Brown, S. M., Cohen, D. n., Hansen, R. n., Kryzer, E. n., Richards, J. n., Small, S. n., Valentine, S. n., York, J. L., Proctor, E. K., Spinella, P. C. 2017; 140 (2)

Abstract

Phlebotomy excess contributes to anemia in PICU patients and increases the likelihood of red blood cell transfusion, which is associated with risk of adverse outcomes. Excessive phlebotomy reduction (EPR) strategies may reduce the need for transfusion, but have not been evaluated in a PICU population. We hypothesized that EPR strategies, facilitated by implementation science methods, would decrease excess blood drawn and reduce transfusion frequency.Quantitative and qualitative methods were used. Patient and blood draw data were collected with survey and focus group data to evaluate knowledge and attitudes before and after EPR intervention. The Consolidated Framework for Implementation Research was used to interpret qualitative data. Multivariate regression was employed to adjust for potential confounders for blood overdraw volume and transfusion incidence.Populations were similar pre- and postintervention. EPR strategies decreased blood overdraw volumes 62% from 5.5 mL (interquartile range 1-23) preintervention to 2.1 mL (interquartile range 0-7.9 mL) postintervention (P < .001). Fewer patients received red blood cell transfusions postintervention (32.1% preintervention versus 20.7% postintervention, P = .04). Regression analyses showed that EPR strategies reduced blood overdraw volume (P < .001) and lowered transfusion frequency (P = .05). Postintervention surveys reflected a high degree of satisfaction (93%) with EPR strategies, and 97% agreed EPR was a priority postintervention.Implementation science methods aided in the selection of EPR strategies and enhanced acceptance which, in this cohort, reduced excessive overdraw volumes and transfusion frequency. Larger trials are needed to determine if this approach can be applied in broader PICU populations.

View details for DOI 10.1542/peds.2016-2480

View details for PubMedID 28701427

View details for PubMedCentralID PMC5527666

Determination of Genetic Predisposition to Patent Ductus Arteriosus in Preterm Infants PEDIATRICS Dagle, J. M., Lepp, N. T., Cooper, M. E., Schaa, K. L., Kelsey, K. J., Orr, K. L., Caprau, D., Zimmerman, C. R., Steffen, K. M., Johnson, K. J., Marazita, M. L., Murray, J. C. 2009; 123 (4): 1116-1123

Abstract

Patent ductus arteriosus is a common morbidity associated with preterm birth. The incidence of patent ductus arteriosus increases with decreasing gestational age to approximately 70% in infants born at 25 weeks' gestation. Our major goal was to determine if genetic risk factors play a role in patent ductus arteriosus seen in preterm infants.We investigated whether single-nucleotide polymorphisms in genes that regulate smooth muscle contraction, xenobiotic detoxification, inflammation, and other processes are markers for persistent patency of ductus arteriosus. Initially, 377 single-nucleotide polymorphisms from 130 genes of interest were evaluated in DNA samples collected from 204 infants with a gestational age of <32 weeks. A family-based association test was performed on genotyping data to evaluate overtransmission of alleles.P values of <.01 were detected for genetic variations found in 7 genes. This prompted additional analysis with an additional set of 162 infants, focusing on the 7 markers with initial P values of <.01, and 1 genetic variant in the angiotensin II type I receptor previously shown to be related to patent ductus arteriosus. Of the initial positive signals, single-nucleotide polymorphisms in the transcription factor AP-2 beta and tumor necrosis factor receptor-associated factor 1 genes remained significant. Additional haplotype analysis revealed genetic variations in prostacyclin synthase to be associated with patent ductus arteriosus. An angiotensin II type I receptor polymorphism previously reported to be associated with patent ductus arteriosus after prophylactic indomethacin administration was not associated with the presence of a patent ductus arteriosus in our population.Overall, our data support a role for genetic variations in transcription factor AP-2 beta, tumor necrosis factor receptor-associated factor 1, and prostacyclin synthase in the persistent patency of the ductus arteriosus seen in preterm infants.

View details for DOI 10.1542/peds.2008-0313

View details for Web of Science ID 000264663100006

View details for PubMedID 19336370

Evaluation of fetal and maternal genetic variation in the progesterone receptor gene for contributions to preterm birth PEDIATRIC RESEARCH Ehn, N. L., Cooper, M. E., Orr, K., Shi, M., Johnson, M. K., Caprau, D., Dagle, J., Steffen, K., Johnson, K., Marazita, M. L., Merrill, D., Murray, J. C. 2007; 62 (5): 630-635

Abstract

Progesterone plays a critical role in the maintenance of pregnancy and has been effectively used to prevent recurrences of preterm labor. We investigated the role of genetic variation in the progesterone receptor (PGR) gene in modulating risks for preterm labor by examining both maternal and fetal effects. Cases were infants delivered prematurely at the University of Iowa. DNA was collected from the mother, infant, and father. Seventeen single nucleotide polymorphisms (SNP) and an insertion deletion variant in PGR were studied in 415 families. Results were then analyzed using transmission disequilibrium tests and log-linear-model-based analysis. DNA sequencing of the PGR gene was also carried out in 92 mothers of preterm infants. We identified significant associations between SNP in the PGR for both mother and preterm infant. No etiologic sequence variants were found in the coding sequence of the PGR gene. This study suggests that genetic variation in the PGR gene of either the mother or the fetus may trigger preterm labor.

View details for Web of Science ID 000250477000022

View details for PubMedID 17805208

Maternal and fetal variation in genes of cholesterol metabolism is associated with preterm delivery JOURNAL OF PERINATOLOGY Steffen, K. M., Cooper, M. E., Shi, M., Caprau, D., Simhan, H. N., Dagle, J. M., Marazita, M. L., Murray, J. C. 2007; 27 (11): 672-680

Abstract

To examine the contribution of variants in fetal and maternal cholesterol metabolism genes in preterm delivery (PTD).A total of 40 single-nucleotide polymorphisms (SNPs) in 16 genes related to cholesterol metabolism were examined for 414 preterm infants (gestational ages 22 to 36 weeks; comprising 305 singletons and 109 twins) and at least 1 parent. Fetal effects were assessed using the transmission disequilibrium test (TDT) for each SNP, followed by a log linear model-based approach to utilize families with missing parental genotypes for those SNPs showing significance under TDT. Genetic variant effects were examined for a role in PTD, gestational age and birth weight. Maternal effects were estimated using a log linear model-based approach.Among singleton gestations, suggestive association (P<0.01 without adjusting for multiple comparisons) was found between birth weight and fetal DHCR7 gene/SNP combinations (rs1630498, P=0.002 and rs2002064, P=0.003). Among all gestations, suggestive associations were found between PTD and fetal HMGCR (rs2303152, P=0.002) and APOA1 (rs 5070, P=0.004). The result for HMGCR was further supported by the log linear model-based test in the single births (P=0.007) and in all births (P=0.006). New associations (APOE and ABCA1) were observed when birth weight was normalized for gestational age suggesting independent effects of variants on birth weight separate from effects on PTD. Testing for maternally mediated genetic effects has identified suggestive association between ABCA1 (rs4149313, P=0.004) and decreased gestational age.Variants in maternal and fetal genes for cholesterol metabolism were associated with PTD and decreased birth weight or gestational age in this study. Genetic markers may serve as one mechanism to identify high-risk mothers and fetuses for targeted nutritional treatment and/or prevention of low birth weight or PTD.

View details for DOI 10.1038/sj.jp.7211806

View details for Web of Science ID 000250444500002

View details for PubMedID 17855807