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. Author manuscript; available in PMC: 2015 Jun 13.
Published in final edited form as: JAMA Otolaryngol Head Neck Surg. 2015 Jan;141(1):27–33. doi: 10.1001/jamaoto.2014.2694

System-Wide Change of Sedation Wean Protocol Following Pediatric Laryngotracheal Reconstruction

Elliott D Kozin 1,2, Brian M Cummings 3, Derek J Rogers 1,2, Brian Lin 1,2, Rosh Sethi 1, Natan Noviski 3, Christopher J Hartnick 1,2
PMCID: PMC4465249  NIHMSID: NIHMS697575  PMID: 25356601

Abstract

Importance

Pediatric laryngotracheal reconstruction (LTR) remains the standard surgical technique for expanding a stenotic airway and necessitates a multidisciplinary team. Sedation wean following LTR is a critical component of perioperative care. We identified variation and communications deficiencies with our sedation wean practice and describe our experience implementing a standardized sedation wean protocol.

Objective

Standardize and decrease length of sedation wean in pediatric patients undergoing LTR.

Design

Using Institute for Healthcare Improvement (IHI) methodology, we implemented system-wide change with the goal of improving care based on best practice guidelines. We created a standardized electronic sedation wean communication document and retrospectively examined our experience in 29 consecutive patients who underwent LTR before (n=16, pre-wean group) and after (n=13, post-wean group) wean document implementation.

Setting

Tertiary care center

Participants

Pediatric patients undergoing LTR

Intervention

Implement standardized sedation protocol

Main Outcomes

Presence of sedation wean document in electronic medical record, length of sedation wean, and need for continued wean after discharge

Results

The sedation wean document was utilized in 92.3% patients of the post-wean group. With the new process, the mean length of sedation wean was reduced from 16.19 (standard deviation [SD] 11.56) days in pre-wean group to 8.92 (SD 3.37) days in the post-wean group, p<0.05. Fewer patients in the post-wean group required continued wean after discharge, 81.3% vs. 33.3%, p<0.05.

Conclusions and Relevance

We implemented system-wide process change with the goal of improving care based on best practice guidelines, which significantly decreased the time required for sedation wean following LTR. Our methodological approach may have implications for other heterogeneous patient populations requiring a sedation wean.

Keywords: outcomes, sedation wean, pediatric airway, laryngotracheal reconstruction, patient safety, root cause analysis

Introduction

Laryngotracheal stenosis remains a significant issue in the pediatric population.1–3 Originally introduced in 1972, laryngotracheal reconstruction (LTR) has evolved to include a variety of techniques for expanding a stenotic airway, including airway reconstruction with a rib cartilage graft.4,5 Through open surgical techniques, success rates in achieving decannulation and avoiding tracheotomy approach 90%.6 Perioperative management involving a multidisciplinary team is vital to the success of airway reconstruction.7–12

During the postoperative period in the pediatric intensive care unit (PICU), the patient is usually nasotracheally intubated, requiring sedation and analgesia with or without neuromuscular blockade. The physical and pharmacologic precautions minimize excessive neck movement that could place tension on the newly repaired airway and decrease movement of the endotracheal tube that could disrupt suture lines and cartilage grafts, cause repeated trauma to the airway mucosa, or result in accidental extubation. Pharmacologic restraints and mechanical ventilation in the PICU typically are necessary for three to seven days, depending on the type of airway reconstruction.5 Following extubation, tapering of sedative medications becomes the primary focus of postoperative care with the goal of avoiding sedative medication withdrawal syndromes.13 Ineffective tapering may result in analgesia-related complications, prolonged hospital stay, increased hospital costs, and family dissatisfaction.14 Research on the best pharmacologic approaches to sedation, neuromuscular blockade and withdrawal monitoring is ongoing.15–17

Similar to other airway centers around the world, at our tertiary care center, sedation wean is recognized as a major postoperative concern in the LTR patient population. While a suggested sedation wean protocol exists in the PICU based on best practice guidelines, actual provider practice varies and the wean approach often changes upon transfer to the ward as implementation of standardized approaches to sedation weaning algorithms in all locations has proven difficult. Further, there is no standardized approach to communication of the sedation wean algorithm during the transfer of LTR patients from the PICU to the ward. Consequently, system-wide variability has resulted in avoidable complications, including over sedation, prolonged weans, and miscommunication among providers in our LTR patient population.

To address system-wide issues in implementing a commonly accepted sedation wean protocol, we turned to the Institute for Healthcare Improvement (IHI) methodology.18 Herein, we describe our experience in applying the IHI methodology to: 1) identify key issues regarding transitions of care, and 2) implement a standardized sedation wean protocol. Given the relatively few patients, as well as similar patient demographics and medical backgrounds, the LTR population represents an ideal patient population to trial a rigorous approach to standardize sedation weans.

Methods

Setting

The study took place at the Massachusetts General Hospital for Children (MGHfC) and Massachusetts Eye and Ear Infirmary (MEEI). MGHfC is a pediatric tertiary care academic hospital that is physically integrated within the Massachusetts General Hospital (MGH). MGHfC has a dedicated PICU, neonatal ICU, pediatric operating rooms (OR), and pediatric patient wards. MGHfC patient wards are managed by pediatricians and associated pediatric specialists. MEEI is an adjacent tertiary care academic medical hospital that treats both adult and pediatric patients. MEEI has a dedicated space for pediatric outpatient visits, operating rooms, and inpatient rooms that are largely managed by pediatric otolaryngologists and pediatric consultant subspecialists. The two hospitals share academic affiliations, some physician and resident coverage, and an electronic health record (EHR) system. MGHfC and MEEI are otherwise distinct facilities in terms of space, support staff, management, and hospital policies.

The Pediatric Airway, Swallowing and Voice Center is an unique collaboration between the MEEI and MGHfC. Patients who require intensive care are transferred from the MEEI operating room to the MGHfC PICU. Pediatric airway patients, such as those undergoing LTR, constitute most of these transfers. Following postoperative care in the PICU, patients are either transferred to the floor at MGHfC or MEEI, depending on individual patient needs. The physically and organizationally unique MEEI-MGHfC relationship potentially exposes our patients to risk for communication breakdown between the providers within each institution.

Ethical Concerns

The Institutional Review Board of the Massachusetts Eye and Ear Infirmary approved retrospective review of patient data. As specific pharmacologic approaches to sedation wean guidelines had previously been established at MGHfC, these guidelines served as a basis for patient management and implementation, ensuring equivalent standard of care to all patients.

Planning the Intervention

Institute for Healthcare Improvement is a recognized healthcare quality improvement organization that provides resources, such as white papers and “Field Guides”, for implementing systemwide change. We used an IHI Field Guide’s seven steps to implement change across two institutions.18 The seven steps comprise forming a team, identifying opportunities for improvement, developing clear aims, designing and testing standard work for key changes, identifying failures or problems and redesigning the process, displaying measures over time to assess progress, and implementing and spreading the reliable design and processes (Fig. 1).

Figure 1. Institute of Healthcare Improvement Algorithm Adapted to Improve Pediatric Sedation Wean in Postoperative LTR Patients.

Figure 1

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IHI 7 steps used to improve outcomes related to sedation wean.

The first step, building a team, is a challenging task, especially multiple physician subspecialists and providers across hospital systems. One strategy to engage providers in safety efforts is to focus on projects that are important to the entire medical staff. At the onset, we organized a focus group led by a senior otolaryngology attending (C.J.H.). In IHI terms, this individual was the “physician champion.” Focus group participants convened in August 2012 and included attending pediatric otolaryngologists, pediatric intensivists, hospitalists, fellows, residents, nurses, pharmacists and social workers. The multidisciplinary focus group reviewed our center’s experience for all LTR patients in 2011 and 2012. Three issues stood out among LTR patients related to sedation wean: 1) prolonged and disparate wean protocols, 2) unanticipated transfer from floor to ICU-level care due to oversedation, and 3) confusion among health care providers regarding sedation wean protocol.

The focus group identified key communication breakdowns typically occurred during transfer of care from the PICU to the MGHfC ward or MEEI ward. The group identified that existing hospital documents, in the PICU and on patient transfer notes to the ward, did not routinely convey a plan for weaning sedation, arguably the main reasons for continued postoperative inpatient status. Sedation wean approaches, which typically consists of methadone and lorazepam tapered at regular intervals, were communicated from physicians to physicians or nurses to nurses, in inconsistent fashion. Additionally, sedation weans typically required management on MGHfC wards instead of MEEI wards due to lack of existing wean protocols at MEEI and training.

Based on information gathered at the focus group, we formulated an IHI-based action plan and developed a “sedation wean document” that contained essential information about the postoperative sedation wean, including dates, times, and dosages of key medications, that was readily comprehensible to all team members. The document was based on previously established MGHfC sedation wean medication calculations and documents; original documents were authored by the MGHfC PICU Withdrawal Committee and adapted from published literature.19 As we previously determined that transfer from the PICU to the ward was the most likely time for communication breakdown, it was determined that the document should be placed in the EHR as a stand-alone document at the time of patient transfer. As the intensivists and associated pediatric residents in the PICU are in charge of the sedation wean medications, it was agreed that they would be the authors of the document and communicate its information to other providers, including otolaryngology and nursing staff.

Methods of Evaluation and Statistical Analysis

We compared the primary outcome of sedation wean length in LTRs from baseline period of 2011–2012 (pre-wean group) and after implementation of the sedation wean document, LTR in 2013–2014 (post-wean group). Additional outcomes included presence of sedation wean document at time of transfer to the floor and discharge (process measure), location of discharge, length of hospital stay and need for continued wean at time of discharge (balance measures). A statistical process control run chart of sedation wean length with baseline data and confidence intervals of 99% was constructed with an Xmr chart, and then reanalyzed following new process utilizing Minitab version 17.1 (Minitab, Inc, State College, PA). Descriptive statistics were used with parametric data presented as mean and standard deviation. Student’s T Test (unpaired) and Fisher’s Exact Test was utilized for study arm comparisons. Statistical analyses were performed by Stata version 12.1 (StataCorp, College Station, TX). All results were considered statistically significant at p<0.05.

Results

Implementation of new process

The sedation wean document was revised several times by stakeholders, with final form completed in February 2013 (Figure 2). The document was converted into an EHR template titled “MGH/MEEI Sedation Wean Plan” accessible by care providers at both hospitals and all three locations. Physicians and nurses at all locations received in-service training for its implementation as a new standard communication tool.

Figure 2. MGH/MEEI Sedation Wean Document.

Figure 2

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Wean document based on best practice guidelines.

Figure 3 provides a run chart of 29 consecutive LTR patients over three and a half-years, with baseline period (pre-wean, n=16) and post process implementation (post-wean, n=13). The process measure of an electronic sedation wean plan was adopted in 12 of 13 eligible patients (92.3%). There are two notable patient outliers in the pre-wean group with length of wean longer than others in the study cohort. These patients had prolonged length of wean due to communication breakdown between providers, resulting in sedation withdrawal syndromes, transfers to the ICU from the floor, and prolonged hospital stays. The first patient in the post intervention period did not have the formal electronic sedation document placed in the EHR. The multidisciplinary team noted the failure and recognized education gaps in pediatric house staff rotating in PICU and subsequent training was provided. Assurance of the presence of the wean document at the time of transfer from the PICU became the responsibility of two physician leaders, a pediatric intensivist (B.C.) and otolaryngology resident (B.L). As the first post-wean implementation period patient did not have a standardized wean document, the patient was excluded from subsequent outcome analyses of the process.

Figure 3. Length of Sedation Wean Run Chart.

Figure 3

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Xmr run chart of consecutive patient sedation wean days with baseline process, and new process, 99% confidence intervals represented with dashed lines. UCL- upper confidence interval; LCL- lower confidence interval; EHR- electronic health record communication form. Note patient 17 was excluded from the analysis, as this patient did not have a standardized wean document.

Patient Demographics Before and After Implementation of Sedation Wean Document

Basic demographic information of the baseline pre-wean and post-wean patients were similar. There were no statistical differences between age (2.55 years +/− 1.42 vs. 1.89 +/− 1.29, p=non significant), female gender (50% vs. 16.67%, p= non significant), continuous sedation infusion duration (8.94 days +/− 3.47 vs. 9.17 days +/− 3.13, p=non significant), length of mechanical ventilation (10.56 days +/− 4.59 vs. 10.25 days +/− 3.41, p=non significant), PICU length of stay (13.44 days +/− 5.37 vs. 13.75 +/− 4.07, p=non significant), and patients with rib cartilage graft (68.8% vs. 91.7%, p=non significant).

Outcomes Following Implementation of Sedation Wean

Table 1 summarizes outcomes between baseline group and patients following the new process. For the primary outcome, mean length of sedation wean was 16.19 (standard deviation [SD] 11.56) days in pre-wean group compared to 8.92 (SD 3.37) days in the post-wean group, p<0.05. Less variation in sedation wean length was also noted with the new process (Figure 3). Fewer patients post-wean process required continued sedation wean after hospital discharge (81.3% vs. 33.3%, p<0.05). In terms of discharge location, there was a decrease in the number of patients discharged from the MGHfC ward (87.5% pre-wean vs. 41.6% post-wean, p=0.017), representing an increase in discharge the PICU and MEEI ward.

Table 1.

Primary Study Outcomes

Pre-Wean
Document
N=16		 Post-Wean
Document
N=12		 P-value
Length of wean (days), Mean (SD) 16.19 (11.56) 8.92 (3.37) 0.0452
Total LOS (days), Mean (SD) 17.88 (5.51) 16.92 (4.01) NS
LOS on ward (days), Mean (SD)* 5.27 (3.56) 4.33 (1.58) NS
Continue wean on discharge (yes), No. (%) 13 (81.3) 4 (33.33) 0.019
Discharge Location
    MEEI Floor, No. (%) 1 (6.3) 4 (33.33) NS
    MGHfC Floor, No. (%) 14 (87.5) 5 (41.67) 0.017
    PICU, No. (%) 1 (6.3) 3 (25) NS
  MGHfC Floor, No. (%) 14 (87.5) 5 (41.7) 0.017
  Non-MGHfC floor location, No. (%) 2 (12.5) 7 (58.3)
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LOS=length of stay; SD=standard deviation; MEEI= Massachusetts Eye and Ear Infirmary; MGHfC=Massachusetts General Hospital for Children; PICU=Pediatric Intensive Care Unit.

*

Patients discharged directly from PICU excluded from analysis (n=1 excluded pre-wean, n=3 excluded post-wean)

In terms of other balance measures, mean length of hospital stay was 17.9 days (SD 5.5) versus 16.9 days (SD 4.0, p=non significant) in pre-wean and post-wean group, respectively. Mean length of days spent on the ward was also similar (5.27 days pre-wean vs. 4.3 days post-wean, p=non significant). (Table 1) In the pre-wean baseline, one patient was required to be transferred from the MEEI ward to PICU due to oversedation during the sedation wean. No patients required return to PICU due to sedation wean failure or oversedation in the post intervention group.

Discussion

Our quality improvement project using IHI methodology demonstrates a significant impact on length of sedation wean following LTR, a critical aspect of post-operative patient care. The new process was well accepted and utilized in 92.3% of eligible patients. Like all process improvement, implementation at the user level is paramount and we quickly responded to our first missed opportunity, dedicating process champions that likely ensured its use. Our primary outcome of sedation wean length demonstrated a nearly 50% decrease in duration, and fewer patients were discharged requiring a narcotics prescription for continued sedation wean, putting less burden on families. Another beneficial impact to the new process was streamlined care, with less patients requiring MGHfC ward care. Prior to the new process, patients would often be transferred to the MGHfC ward for sedation weaning, as nursing and physician staff at MEEI did not have a robust policies of sedation wean practice. The sedation wean multidisciplinary process change enabled PICU and MEEI providers to better manage LTR patients and streamline discharges and location management.

The two groups, pre- and post-wean, were well matched. We had an equivalent patient population between the pre- and post-wean groups in terms of age, sex, and need for a rib graft, which may be considered a general proxy for extent of surgery and potential source of significant post-operative pain. It is important to account for potential differences in the study population in terms of length of mechanical ventilation and continuous sedation as this may be associated with potential increased sedation wean duration. For example, a patient on mechanical ventilation and continuous sedation for three days has a much lower risk for dependence and need for sedation wean compared to a patient on mechanical ventilation and continuous sedation for eight days. We found there was no difference in length of continuous sedation or number of days of mechanical ventilation, which could potentially impact duration needed for sedation wean as longer exposure worsens risk for withdrawal.

In terms of length of stay outcomes, including PICU, ward, and total lengths of stay, we did not identify any differences between the pre- and post-wean study groups. This result is expected, and there are several possible explanations. Principally, length of stay depends more on the timing of the postoperative bronchoscopies than the sedation wean. At our institution, the LTR is followed by two bronchoscopies, the first at the time of extubation when patient is admitted to the PICU and a second around time of discharge when the patient is on the ward, ensuring the continued patency of the airway. The exact timing for the first “second look” bronchoscopy is based on both historic and contemporary LTR studies and typically occurs at our institution around postoperative day seven. In contrast, the timing of the second bronchoscopy typically depends on when the patient is considered safe for discharge, and incorporates multiple factors: wound healing, sedation wean length, swallowing function, physical therapy needs, and family readiness. Therefore, while length in stay in the PICU is relatively fixed, the length of stay on the wards is multifactorial, including sedation wean. The findings of our study are important, as they may indicate that at least one of these major factors necessitating hospitalization on the wards, the sedation wean, can be reduced. As sedation wean is only one factor, it is conceivable that with a larger sample size, one may be able to identify small differences in length of stay on the ward. Moreover, given our findings, one could envision performing the bronchoscopy prior to discharge at an earlier time point during the postoperative period, as the patient may be ready for discharge home sooner. With the advent of new LTR techniques such as the “1.5 stage LTR”, where an endotracheal tube is inserted through the tracheostoma to stent it open in the immediate postoperative period, it may be argued that an earlier second bronchoscopy would be safe as these patients generally have stable airways.20 Future studies will obviously need to address safety and outcomes of an earlier “second look” bronchoscopy. Nevertheless, our data suggests that improvements in sedation wean may theoretically lead to an overall shift in the postoperative timeline of patients undergoing LTR.

In this study, we did not examine the efficacy of our weaning protocol in terms of medications or dosages, but rather examined how changing the process of communication amongst providers with an initial standardized plan could impact discrete outcomes. We acknowledge that recommendations vary and controversy exists regarding sedation wean best practices.21 At our hospital, specific sedative mediations and dosages were adapted from recommendations of a large pediatric research network.19 Further, as part of our sedation wean protocol, we assess withdrawal symptoms every 6 hours to ensure wean is tolerated. We did not study scoring systems or changes in weaning based on patient symptoms. As all our patients had similar continuous infusion exposures, our study is more uniform then previous heterogeneous studies in withdrawal care. Compliance with the actual recommendations is a potential area for further improvement. Of note, our length of sedation wean is significantly shorter than achieved with a pharmacy managed methadone tapering protocol, which reduced average length of weaning from 24 to 15 days.22

Our study fits into the intersection of research on best clinical practices, checklists, and patient handoffs. In terms of best practices, there is often a discrepancy between hospital policy or published guidelines and actual practice patterns. Previous studies have both investigated the implementation of best practices, as well as examined checklists for implementation with positive results.23–29 Furthermore, numerous studies have identified the need for improved communication at the time of patient handoff.30–32 Our sedation wean document was designed to address actively all of these issues simultaneously: implement a system-wide best practice recommendations, provision of a checklist-style document readily available to all patient providers, and focus on communication of the document at time of patient transfer and handoff.

The question arises, “Can IHI methodology be utilized in other more common procedures in otolaryngology, such as tonsillectomy, tracheostomy, or tympanostomy tube placement?” IHI methodology was used to implement systemwide change for the transfer of airway patients from the operating room to the PICU28, as well as in the anesthesia literature.33 In the case of tracheostomy, one can envision generating a uniform electronic form easily interpretable by physicians, nurses, and other providers that would provide standard information, e.g. date of tube placement, type and size of tube, dates of first tracheostomy tube change, and anatomy details, that would travel with the patient during the hospital stay. This type of document would help facilitate communication of critical aspects of patient care and procedure specific outcomes may be studied. Further, previous studies in the otolaryngology literature have addressed patient safety initiatives, such as checklists and wrong-sided surgery.34–36 IHI methodology may be employed to identify system-wide patient safety issues and implement change.

Several potential limitations exist in our study. Our findings may be related to the Hawthorne effect, a phenomenon whereby an individual improves or changes an aspect of his or her behavior in response to a change in the environment. There may have been improvement in postoperative care due to a change in attitudes and behaviors regarding communication spurred by the sedation wean multidisciplinary effort. In terms of transfers to MEEI, it is clear that implementation of the sedation wean document set into place new hospital policies that facilitated patient transfers from the PICU. Also, our small cohort also limits our ability to draw statistical conclusions of our secondary outcome endpoints. The LTR, while readily performed and well studied, it is not a common procedure. Several years of data may be necessary to detect changes in length of stay.

Conclusions

We identified variability in sedation wean practices and opportunities for communication improvement. We implemented system-wide process change using IHI methodology with the goal of improving care based on best practice guidelines, which significantly decreased the time required for sedation wean. Our approach to a sedation wean communication in the LTR patient population may be potentially studied in other more heterogeneous patient populations requiring standardized sedation wean protocols.

Acknowledgments

Funding: No funding was secured for this study

Abbreviations

IHI

Institute for Healthcare Improvement

LTR

Laryngotracheal reconstruction

MEEI

Massachusetts Eye and Ear Infirmary

MGH

Massachusetts General Hospital

Footnotes

Potential Conflicts of Interest: The authors have no conflicts of interest relevant to this article to disclose.

Financial Disclosure: The authors have no financial relationships relevant to this article to disclose.

Presented as an oral presentation at American Society for Pediatric Otolaryngology, May 17th, 2014. Combined Otolaryngological Spring Meeting, Las Vegas, NV.

Author Contributions:

Elliott D. Kozin, M.D.: Project conception, design, data analysis, data acquisition, drafting of manuscript, and approval of paper to be submitted

Brian M. Cummings, M.D.: Project conception, design, data analysis, data acquisition, drafting of manuscript, and approval of paper to be submitted

Derek J. Rogers, M.D. Project conception, design, data analysis, data acquisition, drafting of manuscript, and approval of paper to be submitted

Brian Lin, M.D. : Project design, data analysis, data acquisition, drafting of manuscript, and approval of paper to be submitted

Rosh Sethi, B.S.: Project design, data analysis, data acquisition, drafting of manuscript, and approval of paper to be submitted

Natan Noviski, M.D.: Project design, data analysis, drafting of manuscript, and approval of paper to be submitted

Christopher J. Hartnick, M.D.: Project conception, design, data analysis, data acquisition, drafting of manuscript, and approval of paper to be submitted

References

  • 1.Herrington HC, Weber SM, Andersen PE. Modern management of laryngotracheal stenosis. The Laryngoscope. 2006;116:1553–1557. doi: 10.1097/01.mlg.0000228006.21941.12. [DOI] [PubMed] [Google Scholar]
  • 2.Santos D, Mitchell R. The history of pediatric airway reconstruction. The Laryngoscope. 2010;120:815–820. doi: 10.1002/lary.20823. [DOI] [PubMed] [Google Scholar]
  • 3.Stauffer J, Olson D, Petty T. Complications and conse- quences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med. 1982;70:65–76. doi: 10.1016/0002-9343(81)90413-7. [DOI] [PubMed] [Google Scholar]
  • 4.Fearon B, Cotton R. Surgical correction 2 of subglottic stenosis of the larynx. Preliminary report of an experimental surgical technique. Ann Otol Rhinol Laryngol. 1972;81:508–513. doi: 10.1177/000348947208100408. [DOI] [PubMed] [Google Scholar]
  • 5.Gallagher TQ, Hartnick CJ. Laryngotracheal Reconstruction. Adv Otorhinolaryngol. 2012;73:31–38. doi: 10.1159/000334296. [DOI] [PubMed] [Google Scholar]
  • 6.Cotton RT, gray SD, Miller RP. Update of the Cincinnati Experience in Pediatric Laryngotracheal Reconstruction. The Laryngoscope. 1989:1111–1116. doi: 10.1288/00005537-198911000-00002. [DOI] [PubMed] [Google Scholar]
  • 7.Hammer G. Sedation and analgesia in the pediatric Intensive Care Unit following laryngotracheal reconstruction. Otolaryngologic clinics of North America. 2008;41:1023–1044. doi: 10.1016/j.otc.2008.04.013. [DOI] [PubMed] [Google Scholar]
  • 8.Jacobs BR, Salman BA, Cotton RT, Lyons K, Brill RJ. Postoperative management of children after single-stage laryngotracheal reconstruction. Pediatric Critical Care. 2001;2001:164–168. doi: 10.1097/00003246-200101000-00032. [DOI] [PubMed] [Google Scholar]
  • 9.Roeleveld PP, Hoeve LJ, Joosten KF, de Hoog M. Short use of muscle relaxants following single stage laryngotracheoplasty in children. International journal of pediatric otorhinolaryngology. 2005;69:751–755. doi: 10.1016/j.ijporl.2005.01.006. [DOI] [PubMed] [Google Scholar]
  • 10.Rothschild MA, Cotcamp D, Cotton RT. Postoperative Medical Management in Single-Stage Laryngotracheoplasty. Arch Otolaryngol Head Neck Surg. 1995;121:1175–1179. doi: 10.1001/archotol.1995.01890100081014. [DOI] [PubMed] [Google Scholar]
  • 11.Rowe RW, Betts J, Free E. Perioperative Management for Laryngotracheal Reconstruction. Anesth Analg. 1991;73 doi: 10.1213/00000539-199110000-00020. [DOI] [PubMed] [Google Scholar]
  • 12.Yellon RF, Parameswaran M, Brandom BW. Decreasing morbidity following laryngotracheal reconstruction in children. International journal of pediatric otorhinolaryngology. 1997;41:145–154. doi: 10.1016/s0165-5876(97)00067-0. [DOI] [PubMed] [Google Scholar]
  • 13.Tobias J. Tolerance, withdrawal, and physical dependency after long-term sedation and analgesia of children in the pediatric intensive care unit. Crit Care Med. 2000;28:2122–2232. doi: 10.1097/00003246-200006000-00079. [DOI] [PubMed] [Google Scholar]
  • 14.Wolf A, Jenkins I. Sedation of the critically ill child. Curr Pediatr. 2005;15 [Google Scholar]
  • 15.Playfor S, Jenkins I, Boyles C, et al. Consensus guidelines on sedation and analgesia in critically ill children. Intensive Care Med. 2006;32 doi: 10.1007/s00134-006-0190-x. [DOI] [PubMed] [Google Scholar]
  • 16.Vet NJ, de Wildt SN, Verlaat CW, et al. Daily interruption of sedation in critically ill children: study protocol for a randomized controlled trial. Trials. 2014;15:55. doi: 10.1186/1745-6215-15-55. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Franck L, Scoppettuolo L, Wypij D, Curley M. Validity and generalizability of the Withdrawal Assessment Tool-1 (WAT-1) for monitoring iatrogenic withdrawal syndrome in pediatric patients. Pain. 2012;153:142–148. doi: 10.1016/j.pain.2011.10.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Schall M, Rutherford P, Taylor J, Federico F. Guide for Field Testing: Creating an Ideal Transition to the Clinical Office Practice. Institute for Healthcare Improvement. 2009 [Google Scholar]
  • 19.Anand K, Willson D, Berger J, et al. Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Pediatrics. 2010;125:e1208–e1225. [Google Scholar]
  • 20.Setlur J, Maturo S, Hartnick CJ. Novel Method for Laryngotracheal Reconstruction: Combining Single- and Double-Stage Techniques. Annals of Otology, Rhinology, & Laryngology. 2013;122:445–449. doi: 10.1177/000348941312200706. [DOI] [PubMed] [Google Scholar]
  • 21.Tobias J. Methadone: Who Tapers, When, Where, and How? Pediatric Critical Care Medicine. 2014;15:268–270. doi: 10.1097/PCC.0000000000000080. [DOI] [PubMed] [Google Scholar]
  • 22.Steineck K, Angela K, Carlson M, S G. Evaluation of a Pharmacist-Managed Methadone Taper. Pediatric Critical Care Medicine. 2014;15:206–210. doi: 10.1097/PCC.0000000000000048. [DOI] [PubMed] [Google Scholar]
  • 23.Catchpole KR, Leval MRD, Mcewan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Pediatric Anesthesia. 2007;17:470–478. doi: 10.1111/j.1460-9592.2006.02239.x. [DOI] [PubMed] [Google Scholar]
  • 24.Conroy KM, Elliott D, Burrell AR. Developing content for a process-of-care checklist for use in intensive care units: a dual-method approach to establishing construct validity. BM Health Services. 2013;13 doi: 10.1186/1472-6963-13-380. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Gutsche JT, Kornfield ZN, Speck RM, Patel PA, Atluri P, Augoustides JG. Impact of guideline implementation on transfusion practices in a surgical intensive care unit. Journal of cardiothoracic and vascular anesthesia. 2013;27:1189–1193. doi: 10.1053/j.jvca.2013.05.040. [DOI] [PubMed] [Google Scholar]
  • 26.Hannam JA, Glass L, Kwon J, et al. A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist. BMJ quality & safety. 2013;22:940–947. doi: 10.1136/bmjqs-2012-001749. [DOI] [PubMed] [Google Scholar]
  • 27.Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Annals of surgery. 2010;252:402–407. doi: 10.1097/SLA.0b013e3181e986df. [DOI] [PubMed] [Google Scholar]
  • 28.Kim SW, Maturo S, Dwyer D, et al. Interdisciplinary development and implementation of communication checklist for postoperative management of pediatric airway patients. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2012;146:129–134. doi: 10.1177/0194599811421745. [DOI] [PubMed] [Google Scholar]
  • 29.Byrnes MC, Schuerer DJ, Schallom ME, et al. Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. Critical care medicine. 2009;37:2775–2781. doi: 10.1097/CCM.0b013e3181a96379. [DOI] [PubMed] [Google Scholar]
  • 30.Abraham J, Kannampallil TG, Almoosa KF, Patel B, Patel VL. Comparative evaluation of the content and structure of communication using two handoff tools: Implications for patient safety. Journal of critical care. 2014;29:311, e1–e7. doi: 10.1016/j.jcrc.2013.11.014. [DOI] [PubMed] [Google Scholar]
  • 31.Derienzo C, Lenfestey R, Horvath M, Goldberg R, Ferranti J. Neonatal intensive care unit handoffs: a pilot study on core elements and epidemiology of errors. Journal of perinatology : official journal of the California Perinatal Association. 2014;34:149–152. doi: 10.1038/jp.2013.146. [DOI] [PubMed] [Google Scholar]
  • 32.Vergales J, Addison N, Vendittelli A, et al. Face-to-Face Handoff: Improving Transfer to the Pediatric Intensive Care Unit After Cardiac Surgery. American journal of medical quality : the official journal of the American College of Medical Quality. 2014 doi: 10.1177/1062860613518419. [DOI] [PubMed] [Google Scholar]
  • 33.Gravenstein D, Ford S, Enneking FK. Anesthesiology leadership rounding: identifying opportunities for improvement. The Permanente journal. 2012;16:37–40. doi: 10.7812/TPP/12-050. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Shah RK, Nussenbaum B, Kienstra M, et al. Wrong-site sinus surgery in otolaryngology. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2010;143:37–41. doi: 10.1016/j.otohns.2010.04.003. [DOI] [PubMed] [Google Scholar]
  • 35.Shah RK, Kentala E, Healy GB, Roberson DW. Classification and Consequences of Errors in Otolaryngology. The Laryngoscope. 2004;114:1322–1335. doi: 10.1097/00005537-200408000-00003. [DOI] [PubMed] [Google Scholar]
  • 36.Soler ZM, Smith TL. Endoscopic sinus surgery checklist. The Laryngoscope. 2012;122:137–139. doi: 10.1002/lary.22430. [DOI] [PubMed] [Google Scholar]

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