DOH Orders Termination of “Nurse Volunteer Programs”

Department of Health Secretary Enrique T. ONA, issued memorandum 2011-0238 mandating to terminate all “Nurse Volunteer Programs”, “Volunteer Training Programs for Nurses” and all similar or related programs, in all DOH-retained hospitals in the Philippines.

“The current practice of registered nurses “volunteering” in hospitals to gain ‘work experience’ and/or to obtain a certificate of work experience and for purposes of meeting requirements for employment abroad, is not consistent with the provisions of this law (Republic Act 9418: Volunteer Act of 2007).”

In addition, many hospitals have implemented “nursevolunteerism” in the guise of “training programs” in order to justify the collection of “training fees”, whereby such basic skills training put no added value to the professional career of the nurses.

Therefore, all DOH hospitals are hereby directed to discontinue all existing programs involving nurseswho deliver free services in exchange for work experience/volunteer nurses, volunteer trainings, and all other similar programs. All hospitals-based trainings for nurses should follow a definite career progression to be defined and accredited by the DOH and Professional Regulatory Commision-Board of Nursing.

New Guidelines on Pediatric Brain Death Released

News Author: Allison Gandey
CME Author: Désirée Lie, MD, MSEd

Authors and Disclosures

CME/CE Released: 09/06/2011; Valid for credit through 09/06/2012

Clinical Context

According to the study by Nakagawa and colleagues, in 1987 the guidelines for the determination of brain death in children were published by a multi-society task force. These guidelines emphasized the importance of the history and examination in determining the cause of the coma so that correctable or reversible conditions were eliminated. However, there was insufficient evidence to allow guidance for determining brain death in neonates younger than 7 days old.

This is a statement of several societies to update the 1987 guidelines for determining brain death in children. The guidelines are endorsed by the Society of Critical Care Medicine, The Section for Critical Care and Section of Neurology of the American Academy of Pediatrics, and the American College of Critical Care Medicine.

Study Synopsis and Perspective

New brain death guidelines for infants and children have been issued. Updated for the first time in nearly 25 years, the recommendations provide step-by-step instructions to help guide clinical decision making.

"These revised pediatric death diagnostic guidelines are intended to provide an updated framework in an effort to promote standardization of the neurologic examination and use of ancillary studies," reports the task force, led by Thomas Nakagawa, MD, from Wake Forest University School of Medicine in Winston-Salem, North Carolina.

A standardized checklist, provided to help ensure all components of the examination are carried out, is included as an appendix, the authors note, but they emphasize the importance of supporting families going through the loss of their child.

"Diagnosing brain death must never be rushed or take priority over the needs of the patient or the family," they conclude. "Physicians are obligated to provide support and guidance for families as they face difficult end-of-life decisions and attempt to understand what has happened to their child."

Also involved in the guidelines, published online August 28 in Pediatrics, is the Society of Critical Care Medicine, the American Academy of Pediatrics, and the Child Neurology Society. The document was also reviewed and endorsed by a number of other societies, including the American Academy of Neurology.

Because of insufficient data in the literature, recommendations for preterm infants younger than 37 weeks' gestational age are not included in these recommendations.

2 Exams

"[B]rain death in term newborns, infants and children is a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma," the authors write.

The guidelines state that hypotension, hypothermia, and metabolic disturbances should be treated and corrected. Medications that can interfere with the neurologic examination and apnea testing should be discontinued, allowing for adequate clearance before proceeding.

The task force calls for 2 examinations, including apnea testing, separated by an observation period. They recommend that examinations be performed by different attending physicians. However, apnea testing may be performed by the same physician.

The guidelines recommend an observation period of 24 hours for term newborns to children aged 30 days. For infants and children up to age 18 years, the guidelines call for a 12-hour observation period.

The first examination determines whether the child has met the accepted neurologic examination criteria for brain death, the authors write. The second confirms brain death based on an unchanged and irreversible condition.

The task force suggests that assessment of neurologic function after cardiopulmonary resuscitation or other severe acute brain injuries be deferred for 24 hours or longer if there are concerns or inconsistencies in the examination.

Apnea testing to support the diagnosis of brain death must be performed safely and requires documentation of an arterial PaCO₂ level 20 mm Hg above the baseline and 60 mm Hg or higher, with no respiratory effort, during the testing period. If the apnea test cannot be safely completed, an ancillary study should be performed.

The guidelines state that "[a]ncillary studies (electroencephalogram and radionuclide cerebral blood flow) are not required to establish brain death and are not a substitute for the neurologic examination."

The task force says these studies may be used when components of the examination or apnea testing cannot be completed safely because of the underlying medical condition. They can also be considered if there is uncertainty about the results of the neurologic examination, if a medication effect may be present, or to reduce the interexamination observation period.

When ancillary studies are used, a second clinical examination and apnea test should be performed, and components that can be completed must remain consistent with brain death.

The complete guidelines are available online.

Last June, new brain death guidelines for adults were issued. Unlike these recommendations, the guidelines call for only 1 exam. "The original guideline did not require this either," Gary Gronseth, MD, from the University of Kansas, Kansas City, told Medscape Medical News at the time. "Some people may object, but we found that 1 exam was sufficient."

The guideline authors have disclosed no relevant financial relationships.

Pediatrics. Published online August 28, 2011. Full text

Related Link
Medscape Reference provides a thorough discussion of the impact on child death in an article entitled "Coping with the Death of a Child in the ED."

Study Highlights

• A committee consisting of representatives of various medical societies was formed and charged with providing a checklist and standardization to document brain death in children.
• The multidisciplinary committee, which consisted of physicians and nurses with expertise in pediatrics, pediatric intensive care and critical care medicine, neurology, neurosurgery, and neuroradiology, formed 3 working groups, each charged with reviewing the literature in 3 areas.
• The 3 areas were examination criteria and observation periods; ancillary testing; and declaration of death by medical personnel, including legal and ethical implications.
• A strong recommendation was made if greater than 80% of the committee voted yes, a weak recommendation when less than 80% and more than 20% voted yes, and no recommendation was made if less than 60% of the committee voted yes on a criterion.
• The committee recognized that no national death law existed and that physicians should be familiar with local and state laws and policies.
• The committee also noted that, in some states, the age of the pediatric trauma patient was defined as younger than 14 years old.
• Determination of brain death in newborns, infants, children, and adolescents is based on a clinical diagnosis with absence of neurologic function and a known irreversible cause of coma.
• Recommendations for infants of younger than 37 weeks' gestation are not included in this guideline because of lack of evidence and data.
• 2 examinations, including apnea testing with each examination separated by an observation period, are required.
• The observation period should be no less than 24 hours for term newborns (≥ 37 weeks' gestational age) to age 30 days, and 12 hours for infants and children (ages 30 days to 18 years).
• The 2 examinations should be performed by different attending physicians.
• Qualified clinicians for the examination include pediatric intensivists and neonatologists, pediatric neurologists and neurosurgeons, pediatric trauma surgeons, and pediatric anesthesiologists with critical care training.
• Adult specialists should have special training for children 0 to 18 years old.
• Apnea testing may be performed by the same physician.
• The first examination determines that the child has met the required neurologic criteria for brain death.
• The second examination confirms that the brain death is the result of an irreversible and unchanged condition.
• Assessments after cardiopulmonary resuscitation or other acute brain injuries should be deferred for at least 24 hours or longer if there are concerns or inconsistencies in the examination.
• Apnea testing to support a diagnosis of brain death must be performed safely and requires documentation of arterial PaCO₂ of 20 mm Hg above the baseline and 60 mm Hg and above with no respiratory effort during the testing period.
• If oxygen saturation falls below 85%, hemodynamic stability limits completion of apnea testing, and the child should be placed back on ventilatory support to restore oxygen saturation.
• Another attempt may be made at apnea testing or an ancillary study used to determine brain death.
• If apnea testing cannot be safely completed, an ancillary test should be performed.
• Ancillary studies are not required to establish brain death and should not be used as substitutes for a neurologic examination.
• Ancillary studies are indicated (1) if examination or apnea testing cannot be completed because of the patient's condition; (2) if there is uncertainty about the neurologic examination; (3) if a medication effect may be present; or (4) if the inter-examination observation period needs to be reduced.
• A 4-vessel cerebral angiography is the gold standard for determining absence of cerebral blood flow and must be performed to standards of the American College of Radiology and the Society of Nuclear Medicine.
• Use of electroencephalogram to establish electrocerebral silence and use of radionuclide testing remain the most widely used tests for brain death.
• Electroencephalographic testing must be to the standard of the American Electroencephalographic Society.
• A waiting period of 24 hours is recommended for radionuclide studies for a subsequent study.
• If an ancillary study supports the first neurologic examination diagnosis of brain death, the interobservation interval may be reduced and the second examination and apnea testing performed at any time thereafter for children of all ages.

Clinical Implications

• Determination of brain death in newborns and children requires 2 examinations 24 hours apart, and 2 apnea tests performed by trained specialists.
• Ancillary tests for brain death in newborns and children are used only if the examination or apnea testing cannot be completed, if there is ambiguity about the neurologic examination or a medication effect, or if the interobservation period needs to be reduced.

First-Ever Guidelines Issued for CAP in Infants and Children

News Author: Emma Hitt, PhD
CME Author: Penny Murata, MD

Authors and Disclosures

CME/CE Released: 09/08/2011; Valid for credit through 09/08/2012

Clinical Context

The leading cause of death in children worldwide is pneumonia, as reported by Wardlaw and colleagues in the September 23, 2006, issue of The Lancet. Community-acquired pneumonia (CAP) in children is defined by signs and symptoms of pneumonia in previously healthy children from an infection that was acquired outside of the hospital, according to the British Thoracic Society in the May 2002 issue of Thorax.

The Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) convened an expert panel to review the management of CAP. The PubMed database was reviewed through May 2010. The expert panel included clinicians and investigators who represented community pediatrics, public health, critical care, emergency medicine, hospitalist medicine, infectious diseases, pulmonology, and surgery. These clinical practice guidelines address the management, diagnosis, antimicrobial and adjunct surgical therapy, and prevention of CAP in otherwise healthy children older than 3 months in the outpatient and inpatient settings.

Study Synopsis and Perspective

The first-ever guidelines on the diagnosis and treatment of CAP in infants and children, from PIDS and IDSA, emphasize the importance of immunizations, including a yearly influenza vaccine, to protect children from life-threatening pneumonia.

A 13-member panel, led by John S. Bradley, MD, with the Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, in California, authored the new guidelines published online August 30 and to appear in the print October 1 issue of Clinical Infectious Diseases. The document presents 92 specific recommendations in all, each with varying levels of evidence.

Currently, guidelines exist for the diagnosis and treatment of pneumonia in adults, but in the pediatric setting, bacterial pneumonia often takes a different course, even when caused by the same pathogens. Consequently, there is widespread variability in the treatment of CAP among children.

The current document is "designed to provide guidance in the care of otherwise healthy infants and children and addresses practical questions of diagnosis and management of CAP evaluated in outpatient (offices, urgent care clinics, emergency departments) or inpatient settings in the United States," Dr. Bradley and colleagues write.

Recommendations for Diagnosis

"Diagnostic methods and treatments that work well in adults may be too risky and not have the desired result in children," noted Dr. Bradley in an accompanying written release from the PIDS and IDSA.

Regarding diagnosis, the guidelines state that blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP treated in the outpatient setting.

"In these cases, there is no need to perform unnecessary medical interventions such as using x-rays (which expose the child to radiation needlessly) or prescribing antibiotics (which kill bacteria, not viruses, and may foster drug-resistant bacteria)," the written release states.

However, blood cultures should be performed in children "who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy," the study authors write.

Hospitalization Based on Symptoms in Infants

The guidelines also recommend that infants 3 to 6 months old with suspected bacterial pneumonia be hospitalized, even if the pneumonia is not confirmed by blood tests. "Blood testing in children often isn't accurate, so physicians need to pay close attention to symptoms, and, if unsure, err on the side of treating," Dr. Bradley indicates.

Strong Recommendation for Immunizations

All children and adolescents at least 6 months old should be immunized annually with vaccines for influenza virus to prevent CAP, which the study authors state is a strong recommendation, based on high-quality evidence.

Parents of children younger than 6 months should be vaccinated against influenza because these children cannot receive the preventive vaccine.

Amoxicillin Sufficient for First-Line Therapy

In addition, amoxicillin should be used as first-line therapy for bacterial pneumonia, but more powerful antibiotics are not needed. Methicillin-resistant Staphylococcus aureus should be considered as a cause of pneumonia if first-line treatment is unsuccessful.

According to the guidelines, overtreatment is a critical concern. Most cases of pneumonia in preschool-aged children are of viral origin and will therefore not develop into life-threatening bacterial pneumonia.

Because of the difficulty in studying children, the guidelines all call for more research in several areas.

"With these guidelines, we are hopeful that the standard and quality of care children receive for community-acquired pneumonia will be consistent from doctor to doctor — providing much better treatment outcomes," Dr. Bradley indicates.

"We’re hopeful that in following these guidelines, physicians and hospitals will collect data and the results can be compared," he notes. "We envision this as the first of many revisions of guidelines to come."

Guidelines Meet an Important Unmet Need

Carrie Byington, MD, a pediatric infectious disease specialist with the Department of Pediatrics, at the University of Utah School of Medicine in Salt Lake City, notes that these guidelines address a very important unmet need for all practitioners who care for children.

"Pneumonia is one of the most common reasons for hospitalization for children in the United States, and there's a huge variation in the care that's delivered to children," she told Medscape Medical News. Dr. Byington is an author on the new guidelines and is vice chair of the American Academy of Pediatrics Committee on Infectious Diseases.

"Often the care of children is not evidence based and result in both over- and undertreatment of children and less than ideal outcomes," she said. "This is the first attempt to review all the evidence available in the scientific literature and to provide explicit guidelines for practitioners that could assist them in their decision making for children with pneumonia."

Areas of Interest

According to Dr. Byington, pediatricians in primary care will probably be most interested in the guidelines for diagnostic testing and the recommendation for antibiotic therapy. Pediatricians in the hospital setting will also be interested in the guidelines for hospitalized children, including diagnostic testing and treatment of complicated pneumonia.

"We also really want to stress the prevention of pneumonia through immunization, so there is a large section to the research that demonstrates the importance of this," she said.

This study was supported by the IDSA. Some of the study authors have disclosed various financial relationships with Wyeth/Pfizer, Sanofi Pasteur, Pfizer, GlaxoSmithKline, Novartis, Baxter Health Care, Halozyme Therapeutics, Pricara (Ortho-McNeil-Janssen), Rox-888, Venasite, the National Institutes of Health, and/or the Robert Wood Johnson Foundation.

Clin Infect Dis. Published online August 30, 2011.

Related Link
Medscape Reference provides an in-depth review of Pediatric Pneumonia.

Study Highlights

• Indications for hospitalization are moderate to severe CAP based on respiratory distress and hypoxemia (SpO₂ < 90%), age younger than 3 to 6 months, suspected bacterial cause, virulent pathogen, and concern about home care or follow-up.
• Indications for admission to the intensive care unit are the need for ventilation, impending respiratory failure, sustained tachycardia, inadequate blood pressure or perfusion, pulse oximetry reading of less than 92% on 0.50 or more of inspired oxygen, and altered mental status.
• Blood culture indications are no improvement after initiation of antibiotic use, hospitalization for moderate to severe or complicated bacterial CAP, or follow-up of blood culture results positive for S aureus.
• If indicated, tests can be done for sputum Gram stain and culture, respiratory viruses, and Mycoplasma pneumoniae.
• Complete blood cell count should be obtained in cases of severe pneumonia.
• Acute-phase reactants (erythrocyte sedimentation rate, C-reactive protein, serum procalcitonin levels) should not be used to distinguish a viral vs bacterial cause, but they can be useful for serious disease.
• Pulse oximetry is indicated in all children with pneumonia and suspected hypoxemia.
• Chest radiographs should be done in the outpatient setting for cases of hypoxemia, significant respiratory distress, or failed antibiotic therapy and should also be performed in all hospitalized patients.
• Follow-up chest radiographs are recommended in children whose condition does not improve within 48 to 72 hours after starting antibiotic therapy and for cases of recurrent pneumonia involving the same lobe.
• Most preschool-aged children with CAP have a viral pathogen and do not require antimicrobial therapy in the outpatient setting.
• Anti-infective treatment in the outpatient setting includes the following:
  • Amoxicillin to treat Streptococcus pneumoniae in previously healthy, appropriately immunized infants, preschool-aged children, and school-aged children with mild to moderate bacterial CAP
  • Macrolide antibiotic for primarily school-aged children with CAP from a suspected atypical pathogen
  • Influenza antiviral treatment of moderate to severe CAP from suspected influenza, despite pending or negative influenza test results
• Anti-infective treatment in the inpatient setting includes the following:
  • Ampicillin or penicillin G for fully immunized infants or school-aged children
  • Third-generation parenteral cephalosporin (ceftriaxone or cefotaxime) for cases of incomplete immunization, in locations of invasive pneumococcal strains with high-level penicillin resistance, and life-threatening infection
  • Empiric addition of an oral or parenteral macrolide to a beta-lactam antibiotic for suspectedMycoplasma pneumoniae and Chlamydophila pneumoniae
  • Vancomycin or clindamycin plus a beta-lactam antibiotic for suspected S aureus
• The appropriate antimicrobial treatment duration is 10 days, but shorter courses might be effective or longer courses might be needed.
• Parapneumonic effusion identified by chest radiograph, ultrasonography, or computed tomography might need drainage, depending on its size and degree of respiratory compromise.
• Options for parapneumonic effusion drainage are chest thoracostomy tube drainage plus fibrinolytic agents or video-assisted thoracoscopic surgery.
• Criteria for hospital discharge include overall clinical improvement for at least 12 to 24 hours, pulse oximetry of more than 90% in room air for at least 12 to 24 hours, baseline mental status, ability to tolerate home anti-infective and oxygen regimens, no deterioration 12 to 24 hours after removal of the chest tube, and attention to barriers to home care.
• Appropriate immunization for children and caregivers can prevent CAP.

Clinical Implications

• The recommended anti-infective treatment of previously healthy, appropriately immunized children in the outpatient setting includes amoxicillin for preschool and school-aged children with mild to moderate bacterial CAP, macrolide antibiotics for school-aged children with suspected atypical bacterial pathogens, and influenza antiviral treatment in children with moderate to severe CAP from a suspected influenza virus.
• The recommended anti-infective treatment of children hospitalized with CAP includes ampicillin or penicillin G for appropriately immunized children; a third-generation parenteral cephalosporin for children who are not fully immunized, those in locations with high-level penicillin resistance, or in cases of life-threatening infection; macrolide treatment plus a beta-lactam antibiotic for suspected M pneumoniae and C pneumoniae; and vancomycin or clindamycin plus beta-lactam treatment of suspected S aureus.