James C. Fackler's research while affiliated with Vanderbilt University and other places
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Publications (132)
Background:
Blood cultures are overused in pediatric ICUs (PICUs), which may lead to unnecessary antibiotic use and antibiotic resistance. Using a participatory ergonomics (PE) approach, the authors disseminated a quality improvement (QI) program for optimizing blood culture use in PICUs to a national 14-hospital collaborative. The objective of th...
Background:
Pediatric anesthesia has evolved to a high level of patient safety, yet a small chance remains for serious perioperative complications, even in those traditionally considered at low risk. In practice, prediction of at-risk patients currently relies on the American Society of Anesthesiologists Physical Status (ASA-PS) score, despite rep...
Introduction: Mechanical ventilation is a life-saving treatment in the Intensive Care Unit (ICU), but often causes patients to be at risk of further respiratory complication. We created a statistical model utilizing electronic health record and physiologic vitals data to predict the Center for Disease Control and Prevention (CDC) defined Ventilator...
Background:
Cardiac arrest is a leading cause of mortality prior to discharge for children admitted to the pediatric intensive care unit. To address this problem, we used machine learning to predict cardiac arrest up to three hours in advance.
Methods:
Our data consists of 240 Hz ECG waveform data, 0.5 Hz physiological time series data, medicati...
Importance:
Blood culture overuse in the pediatric intensive care unit (PICU) can lead to unnecessary antibiotic use and contribute to antibiotic resistance. Optimizing blood culture practices through diagnostic stewardship may reduce unnecessary blood cultures and antibiotics.
Objective:
To evaluate the association of a 14-site multidisciplinar...
Background:
The care of pediatric trauma patients is delivered by multidisciplinary care teams with high fluidity that may vary in composition and organization depending on the time of day.
Objective:
This study aims to identify and describe diurnal variations in multidisciplinary care teams taking care of pediatric trauma patients using social...
Background
Mechanical ventilation is a life-saving treatment in the Intensive Care Unit (ICU), but often causes patients to be at risk of further respiratory complication. We created a statistical model utilizing electronic health record and physiologic vitals data to predict the Center for Disease Control and Prevention (CDC) defined Ventilator As...
Diagnosing critically ill patients in the intensive care unit is difficult. As a result, diagnostic errors in the intensive care unit are common and have been shown to cause harm. Research to improve diagnosis in critical care medicine has accelerated in past years. However, much work remains to fully elucidate the diagnostic process in critical ca...
Background: High flow nasal cannula (HFNC) is commonly used as non-invasive respiratory support in critically ill children. There are limited data to inform consensus on optimal device parameters, determinants of successful patient response, and indications for escalation of support. Clinical scores, such as the respiratory rate-oxygenation (ROX) i...
Introduction:
Accurate assessment of infection in critically ill patients is vital to their care. Both indiscretion and under-utilization of diagnostic microbiology testing can contribute to inappropriate antibiotic administration or delays in diagnosis. However, indiscretion in diagnostic microbiology cultures may also lead to unnecessary tests t...
Objective: The objective of the study is to build models for early prediction of risk for developing multiple organ dysfunction (MOD) in pediatric intensive care unit (PICU) patients.
Design: The design of the study is a retrospective observational cohort study.
Setting: The setting of the study is at a single academic PICU at the Johns Hopkins Hos...
Guideline-based treatment for sepsis and septic shock is difficult because sepsis is a disparate range of life-threatening organ dysfunctions whose pathophysiology is not fully understood. Early intervention in sepsis is crucial for patient outcome, yet those interventions have adverse effects and are frequently overadministered. Greater personaliz...
Group Name: Bright STAR Authorship Group
Background: Blood cultures are fundamental in the diagnosis and treatment of sepsis. Culture practices vary widely, and overuse can lead to false-positive results and unnecessary antibiotics. Our objective was to describe the implementation of a multisite quality improvement collaborative to reduce unnecessa...
Objectives:
Sepsis and septic shock are leading causes of in-hospital mortality. Timely treatment is crucial in improving patient outcome, yet treatment delays remain common. Early prediction of those patients with sepsis who will progress to its most severe form, septic shock, can increase the actionable window for interventions. We aim to extend...
BACKGROUND
The care of pediatric trauma patients is delivered by multidisciplinary care teams with high fluidity that may vary in composition and organization depending on the time of day.
OBJECTIVE
This study aims to identify and describe diurnal variations in multidisciplinary care teams taking care of pediatric trauma patients using social netw...
Objectives:
Blood cultures are fundamental in evaluating for sepsis, but excessive cultures can lead to false-positive results and unnecessary antibiotics. Our objective was to create consensus recommendations focusing on when to safely avoid blood cultures in PICU patients.
Design:
A panel of 29 multidisciplinary experts engaged in a two-part m...
Objectives:
To summarize the literature on prevalence, impact, and contributing factors related to diagnostic error in the PICU.
Data sources:
Search of PubMed, EMBASE, and the Cochrane Library up to December 2019.
Study selection:
Studies on diagnostic error and the diagnostic process in pediatric critical care were included. Non-English stud...
Background:
Clinicians commonly obtain endotracheal aspirate cultures (EACs) in the evaluation of suspected ventilator-associated infections. However, bacterial growth in EACs does not distinguish bacterial colonization from infection and may lead to overtreatment with antibiotics. We describe the development and impact of a clinical decision supp...
Sepsis is a syndrome which afflicts both adults and children, with many disease courses and diverse outcomes. Understanding of sepsis pathophysiology has changed over time; the Sepsis-3 criteria define sepsis in adults as organ dysfunction, quantified by SOFA score, caused by dysregulated immune response to infection. However, pediatric consensus d...
Background: Blood cultures are essential diagnostic tools used to identify bloodstream infections and to guide antimicrobial therapy. However, collecting cultures without clear indications or that do not inform management can lead to false-positive results and unnecessary use of antibiotics. Blood culture practices vary significantly in critically...
Sepsis is not a monolithic disease, but a loose collection of symptoms with diverse outcomes. Thus, stratification and subtyping of sepsis patients is of great importance. We examine the temporal evolution of patient state using our previously-published method for computing risk of transition from sepsis into septic shock. Risk trajectories diverge...
Sepsis is not a monolithic disease, but a loose collection of symptoms with diverse outcomes. Thus, stratification and subtyping of sepsis patients is of great importance. We examine the temporal evolution of patient state using our previously-published method for computing risk of transition from sepsis into septic shock. Risk trajectories diverge...
Sepsis is not a monolithic disease, but a loose collection of symptoms with diverse outcomes. Thus, stratification and subtyping of sepsis patients is of great importance. We examine the temporal evolution of patient state using our previously-published method for computing risk of transition from sepsis into septic shock. Risk trajectories diverge...
Background:
Clinical intuition and nonanalytic reasoning play a major role in clinical hypothesis generation; however, clinicians' intuition about whether a critically ill child is bacteremic has not been explored. We endeavored to assess pediatric critical care clinicians' ability to predict bacteremia and to evaluate what affected the accuracy o...
Background:
Craniosynostosis is the premature fusion of ≥1 cranial sutures and often requires surgical intervention. Surgery may involve extensive osteotomies, which can lead to substantial blood loss. Currently, there are no consensus recommendations for guiding blood conservation or transfusion in this patient population. The aim of this study i...
Introduction:
The dissemination of quality improvement (QI) interventions to a broader range of healthcare settings requires a proactive assessment of local work systems and processes. The objective of this study was to examine the feasibility of using a survey-based work system assessment (WSA) tool to facilitate the dissemination of a program fo...
Sepsis is not a monolithic disease, but a loose collection of symptoms with a diverse range of outcomes. The diverse patterns of sepsis make guideline-driven treatment difficult, as guidelines are based on the needs of the "average" patient. Thus, stratification and subtyping of sepsis patients is of interests, with the ultimate goal of identifying...
Understanding reasons clinicians obtained endotracheal aspirate cultures and impact on patient management to inform diagnostic stewardship initiatives - Anna C. Sick-Samuels, James C. Fackler, Sean M. Berenholtz, Aaron M. Milstone
Objectives:
Sending blood cultures in children at low risk of bacteremia can contribute to a cascade of unnecessary antibiotic exposure, adverse effects, and increased costs. We aimed to describe practice variation, clinician beliefs, and attitudes about blood culture testing in critically ill children.
Design:
Cross-sectional electronic survey....
Background
Clinicians obtain endotracheal aspirate (ETA) cultures from mechanically ventilated patients in the pediatric intensive care unit (PICU) for the evaluation of ventilator-associated infection (i.e., tracheitis or pneumonia). Positive cultures prompt clinicians to treat with antibiotics even though ETA cultures cannot distinguish bacterial...
Septic shock is a life-threatening condition in which timely treatment substantially reduces mortality. Reliable identification of patients with sepsis who are at elevated risk of developing septic shock therefore has the potential to save lives by opening an early window of intervention. We hypothesize the existence of a novel clinical state of se...
Blood cultures are essential for the evaluation of sepsis. However, they may sometimes be obtained inappropriately, leading to high false-positive rates, largely due to contamination. ¹ As a quality improvement project, clinician decision-support tools for evaluating patients with fever or signs and symptoms of sepsis were implemented in April 2014...
Objective To describe physician perceptions of the potential goals, characteristics, and content of the electronic problem list (PL) in pediatric trauma.
Methods We conducted 12 semistructured interviews with physicians involved in the pediatric trauma care process, including residents, fellows, and attendings from four services: emergency medicine...
The EHR problem list has the potential to support care coordination among the multidisciplinary care team that cares for pediatric trauma patients. To realize this potential, the need exists to ensure appropriate utilization by formulating acceptable usage and management policy. In this regard, understanding the prevailing utilization pattern is pi...
Introduction:
Single center work demonstrated a safe reduction in unnecessary blood culture use in critically ill children. Our objective was to develop and implement a customizable quality improvement framework to reduce unnecessary blood culture testing in critically ill children across diverse clinical settings and various institutions.
Method...
Background Inhospital pediatric trauma care typically spans multiple locations, which influences the use of resources, that could be improved by gaining a better understanding of the inhospital flow of patients and identifying opportunities for improvement.
Objectives To describe a process mining approach for mapping the inhospital flow of pediatri...
Multistate Outbreak of an Emerging Burkholderia cepacia Complex Strain Associated With Contaminated Oral Liquid Docusate Sodium - Volume 39 Issue 2 - Ibukunoluwa C. Akinboyo, Anna C. Sick-Samuels, Emily Singeltary, James Fackler, Judith Ascenzi, Karen C. Carroll, Yvonne Maldonado, Richard B. Brooks, Isaac Benowitz, Lucy E. Wilson, John J. LiPuma, A...
Objectives:
The objectives of this research were to describe the interactions (formal and informal), in which macrocognitive functions occur and their location on a pediatric intensive care unit, to describe challenges and facilitators of macrocognition using space syntax constructs (openness, connectivity, and visibility), and to analyze the heal...
Importance:
Sepsis and septic shock are common and, at times, fatal in pediatrics. Blood cultures are often obtained when clinicians suspect sepsis, yet are low-yield with a false-positive rate up to 50%.
Objectives:
To determine whether a novel, 2-part, clinical practice guideline could decrease the rates of total blood cultures and cultures co...
Background:
Work system assessments can facilitate successful implementation of quality improvement programs. Using a human factors engineering approach, we conducted a work system assessment to facilitate the dissemination of a quality improvement program for optimizing blood culture use in pediatric intensive care units at 2 hospitals.
Methods:...
Importance:
The capacity of pediatric hospitals to provide treatment to large numbers of patients during a large-scale disaster remains a concern. Hospitals are expected to function independently for as long as 96 hours. Reverse triage (early discharge), a strategy that creates surge bed capacity while conserving resources, has been modeled for ad...
Objective:
Determine the effectiveness of a structured systems-oriented morbidity and mortality conference in improving the process of reviewing and responding to adverse events in a PICU.
Design:
Prospective time series analysis before and after implementation of a systems-oriented morbidity and mortality conference.
Setting:
Single tertiary...
Background:
Although prior studies support the use of a hemoglobin (Hb) transfusion trigger of 7 to 8 g/dL for most hospitalized adults, there are few studies in pediatric populations. We therefore investigated transfusion practices and Hb triggers in hospitalized children.
Study design and methods:
We performed a historical cohort study compari...
To describe diagnostic errors identified among patients discussed at a PICU morbidity and mortality conference in terms of Goldman classification, medical category, severity, preventability, contributing factors, and occurrence in the diagnostic process.
Retrospective record review of morbidity and mortality conference agendas, patient charts, and...
Critically insufficient pediatric hospital capacity may develop during a disaster or surge event. Research is lacking on the creation of pediatric surge capacity. A system of "reverse triage," with early discharge of hospitalized patients, has been developed for adults and shows great potential but is unexplored in pediatrics.
We conducted an evide...
Objective To determine if standardised chart review applied to records of patients discussed at a paediatric intensive care unit (PICU) morbidity and mortality conference (MMC) yields additional or different information regarding safety event occurrence and characteristics.
Design Retrospective record review.
Setting Single tertiary referral PICU i...
Objective:
Determine how many morbidity and mortality conferences in PICUs across the United States conform to key elements of medical incident analysis.
Design:
Web-based cross-sectional survey open from March to September 2013.
Setting:
Seventy-five PICUs with regular morbidity and mortality conferences in the United States identified by cro...
Introduction: In addition to traditional incident reporting, the MMC can augment the ability to surface AEs. Our objective is to determine the types, severity and preventability of AEs uncovered among patients discussed in a tertiary hospital PICU MMC over a specific time period and compare these with AEs reported for the same cohort through the ho...
Purpose: The optimal hemoglobin (Hb) threshold at which to transfuse pediatric patients is unknown. A study in pediatric intensive care unit (PICU) patients found that a restrictive hemoglobin threshold (7 g/dL) was not associated with adverse outcomes as compared to a more liberal threshold (9.5 g/dL). Studies in adults show significant variation...
Unlabelled:
Hospital relocation is a highly complex undertaking, which has the potential to interrupt operations and poses risks for patients, staff, and providers. Little is known how hospital relocation impacts on workflow and communication.
Methods:
Using existing Electronic Health Record (EHR) data we determined time from medication ordering...
Unlabelled:
The complexity and high cost of neonatal and pediatric intensive care has generated increasing interest in developing measures to quantify the severity of patient illness. While these indices may help improve health care quality and benchmark mortality across hospitals, comprehensive understanding of the purpose and the factors that in...
This panel session is designed to explore the reasons why healthcare fails to adopt simulation and modeling techniques, and will seek to highlight ways towards greater adoption. The aim of the panel is to have a sustained dialogue with and amongst the audience. The agenda for the discussion will cover care delivery in a variety of contexts, includi...
Objective:
To develop a model to produce real-time, updated forecasts of patients' intensive care unit length of stay using naturally generated provider orders. The model was designed to be integrated within a computerized decision support system to improve patient flow management.
Design:
Retrospective cohort study.
Setting:
Twenty-six bed pe...
Physicians do modeling - every day, all day. It's just that it's done with hideous imprecision making cross-patient conclusions hazardous and extensibility impossible. Most of these mental models are devoid of formal logic. Rather, these mental models are patterns matched in a specific patient with a specific problem(s) based on a clinician's exper...
To understand expert and team cognition of complex patients in the pediatric intensive care unit through the use of cognitive task analysis.
Qualitative study with semistructured interviews.
Academic medical center pediatric intensive care unit.
Physicians, nurses, and nurse practitioners.
None.
Semistructured interviews were conducted with members...
Children with viral respiratory infections who undergo general anesthesia are at increased risk of respiratory complications. We investigated the impact of RSV and influenza infection on perioperative outcomes in children undergoing general anesthesia.
We performed a retrospective case-control study. All patients under the age of 18 years who under...
To investigate the association of method of acquisition (hospital-acquired vs. community-acquired) and mortality in children with severe viral respiratory infection.
Retrospective cohort study.
: Pediatric intensive care unit at an urban academic tertiary care children's hospital.
All patients aged <18 yrs admitted to our pediatric intensive care u...
Respiratory syncytial virus (RSV) is the most common cause of documented viral respiratory infections, and the leading cause of hospitalization, in young children. We performed a retrospective time-series analysis of all patients aged <18 years with laboratory-confirmed RSV within a network of multiple affiliated academic medical institutions. Fore...