Improving the quality of care in pediatric patients with cirrhosis.

Background: Coronavirus disease 2019 (COVID-19) pandemic-related refocusing of healthcare along with needs for social distancing, complete or partial lockdowns, and burgeoning economic crisis has created immense barriers to the access of healthcare services by the non-COVID patients. Aim: We aimed to assess the perspectives of Indian healthcare workers taking care of pediatric patients on the barriers to healthcare delivery to pediatric non-COVID illnesses. Methods: Indian healthcare workers, working in both public and private sectors, taking care of pediatric patients were surveyed using a predesigned pretested online questionnaire over a period of 1 month (May 2020). The impact on healthcare delivery was graded using a Likert scale. Results: Of the total of 356 responses obtained, 75.3% reported a significant negative impact of the COVID-19 pandemic on delivery of healthcare to non-COVID pediatric patients. Respondents of government and COVID hospitals reported a significantly worse impact than private (P = 0.0002) and non-COVID hospitals (P = 0.01), respectively. Significant decline in number of non-COVID patients attending outpatient department (86.2%), admitted in wards (71.6%), number of routine (81.7%) and emergency surgeries (60.5%), number of diagnostic procedures (61.2%), and scheduled therapies (50.2%) was reported by the surveyed healthcare workers. Most important factors for disrupted healthcare delivery were restricted travel (78.3%) and fear of contracting COVID-19 (68.8%). Telemedicine (67.4%) was the commonest alternate strategy deployed for continuing care of patients. Conclusion: Several challenges exist to maintain the continuity of healthcare services to pediatric non-COVID patients especially in those with chronic diseases, poor financial background, and follow-up in COVID government hospitals. Use of telemedicine, strategic preplanning, strengthening peripheral healthcare, and optimal resource reallocation may help reduce the broader health impact of the COVID-19 pandemic.

Background: Patient and family-centered care is one approach that is applied in pediatric care in various hospital settings to improve the quality of care. However, information related to the results of the entire study and its intervention model has not been identified effectively in child health care.Purpose: This study aimed to describe and assess the effects of patient and family-centered care on the quality of care in pediatric patients.Methods: A systematic review was used as a method in this study. Seven databases were used, including ScienceDirect, Scopus, ProQuest, EBSCO, Sage Journal, Tailor and Francis, and PubMed to search the literature for relevant published reviews that determined patient and family-centered care interventions between 2011 and 2021. The synthesis without meta-analysis guidelines was used to analyze the data in this review. The data were further analyzed by critically assessing the quality of the articles using the JBI and CASP checklists.Results: From a total of 29.780 articles identified, fifteen articles were included in this review. Several models of patient and family-centered care interventions were identified, such as family-centered care, family-centered communication program, family-integrated care, family nurture intervention, family empowerment, parent participation, close collaboration, mother-nurse partnership program, and the newborn individualized developmental care and assessment program. From those models, the outcomes for quality of care were related to the pediatric quality of life, length of stay, patient safety, parent satisfaction, parent psychological response, and parent involvement and partnership with staff.Conclusion: The shreds of evidence indicate that patient and family-centered care can improve the quality of care in the pediatric patients. It is recommended that patient and family-centered care can be implemented in pediatric care by increasing the participation of family during treatment.

Several studies show that emergency medicine (EM) physicians are less comfortable caring for pediatric patients than adults. The state of pediatric training has not been comprehensively evaluated since 2000. We sought to describe current pediatric education in EM residencies and to evaluate EM Program Director (PD) confidence in graduating trainees' abilities to care for pediatric patients. We conducted an anonymous, cross-sectional survey study of EM PDs in August 2020. We collected program demographics, clinical rotations, and didactic methods. We used Likert scales to measure PD confidence in graduating residents' competence to care for pediatric and adult patients. We found e-mail addresses for 249 (93%) of 268 EM programs. One hundred nineteen (48%) PDs completed the survey. We include denominators to account for unanswered questions. Sixty-eight (59%) of 116 programs spend 10% to 20% of clinical time seeing pediatric patients. One hundred ten (91%) of 119 require a pediatric emergency medicine (PEM) rotation, 88/119 (83%) require pediatric intensive care, and 34/119 (29%) require neonatal intensive care. Seventy (62%) of 113 have curricula designed by PEM-trained faculty, 96/113 (85%) have PEM attendings teach lectures, and 77/113 (68%) spend 10% to 20% of didactic time on pediatric topics. Twenty-three (23%) of 106 PDs stated not all residents graduate with competence in pediatric resuscitation compared with 2/106 (2%) for adult resuscitation ( P < 0.05). Program directors report less confidence in graduating residents' competence in caring for pediatric patients compared with adult patients. We propose ideas to strengthen the quality of pediatric education in EM residencies.

Invited Commentary

Efficacy and feasibility of opioids for burn analgesia: An evidence-based qualitative review of randomized controlled trials

Traumatic brain injury (TBI) is a major cause of death and disability in the pediatric population. The authors assessed 1-year costs of intensive care in pediatric TBI patients. In this retrospective multicenter cohort study of four academic ICUs in Finland, the authors used the Finnish Intensive Care Consortium database to identify children aged 0-17 years treated for TBI in ICUs between 2003 and 2013. The authors reviewed all patient health records and head CT scans for admission, treatment, and follow-up data. Patient outcomes included functional outcome (favorable outcome defined as a Glasgow Outcome Scale score of 4-5) and death within 6 months. Costs included those for the index hospitalization, rehabilitation, and social security up to 1 year after injury. To assess costs, the authors calculated the effective cost per favorable outcome (ECPFO). In total, 293 patients were included, of whom 61% had moderate to severe TBI (Glasgow Coma Scale [GCS] score 3-12) and 40% were ≥ 13 years of age. Of all patients, 82% had a favorable outcome and 9% died within 6 months of injury. The mean cost per patient was €48,719 ($54,557) (95% CI €41,326-€56,112). The index hospitalization accounted for 66%, rehabilitation costs for 27%, and social security costs for 7% of total healthcare costs. The ECPFO was €59,727 ($66,884) (95% CI €52,335-€67,120). A higher ECPFO was observed among patients with clinical and treatment-related variables indicative of parenchymal swelling and high intracranial pressure. Lower ECPFO was observed among patients with higher admission GCS scores and those who had epidural hematomas. Greater injury severity increases ECPFO and is associated with higher postdischarge costs in pediatric TBI patients. In this pediatric cohort, over two-thirds of all resources were spent on patients with favorable functional outcome, indicating appropriate resource allocation.

Access to care for pediatric hospice patients is inhibited by a lack of providers specifically educated to care for pediatric patients. Education that seeks to address this gap in care must develop the specific knowledge and skills required to care for pediatric patients, and this education must also be delivered in a format that enables convenient access to providers. This article describes the development of an innovative blended curriculum to build upon the existing knowledge base and skill set required by experienced adult hospice care providers to expand care for pediatric patients. The article elucidates how the community of practice framework and Bloom’s taxonomy informed the blended curriculum leveraging both online, asynchronous modules and virtual, synchronous precepting sessions and also informed the selection of content, activities, and assessment methods aligned to requisite competencies and skills. It also details the identification of requisite competencies and skills and the next steps in piloting this intervention.

To investigate the provision of care for pediatric and adolescent patients by gynecologic oncologists. The present prospective cross-sectional study enrolled attending physicians and fellows specializing in gynecologic oncology from the USA during December 2012 and January 2013. A 33-question survey collecting demographic data and details of participant opinions on existing practices was distributed to potential respondents. Survey responses were aggregated and descriptive analyses were performed. The survey was distributed to 1252 physicians and 178 (14.2%) surveys were returned; 105 (59.0%) participants thought that the care of patients aged younger than 21years should be included in their practice. Only 7 (3.9%) participants had received formal training in caring for pediatric patients and young adults; however, 85 (47.8%) felt this should be incorporated into formal fellowship training. Multidisciplinary teams were reported to be the best method for caring pediatric patients by 160 (88.9%) participants but only 42 (23.6%) participants reported that multidisciplinary teams were involved in pediatric gynecologic oncology care at their institutions. Gynecologic oncologists wanted to be involved in pediatric care and open dialogue between specialists could help in the provision of optimal, longitudinal care to these patients. Furthermore, the incorporation of formal pediatric patient-focused training into gynecologic oncology fellowship programs should be considered.

Este artículo proporciona una visión integral de los cuidados paliativos oncológicos en pacientes pediátricos, destacando la importancia de una atención integral y multidisciplinaria para mejorar la calidad de vida en esta población vulnerable. La atención paliativa se enfoca en brindar apoyo integral a niños que padecen cáncer y a sus familias, con el objetivo de mejorar su calidad de vida y aliviar el sufrimiento tanto físico como emocional, a diferencia del tratamiento curativo, los cuidados paliativos se centran en el control de los síntomas, el manejo del dolor y el apoyo emocional, proporcionando un enfoque holístico para el bienestar del niño. Los objetivos de la revisión radicaron en analizar las diversas modalidades de intervención en cuidados paliativos oncológicos que se adapten a las necesidades específicas de los pacientes pediátricos y describir la influencia de los cuidados paliativos en la calidad de vida de los pacientes y sus familias. Materiales y métodos: se realizó una revisión sistemática de la literatura, de artículos científicos de los últimos 5 años tanto en el idioma inglés como español, se seleccionaron 15 referencias bibliográficas tomando en cuenta su veracidad e impacto. Los resultados obtenidos sugieren que la implementación adecuada de cuidados paliativos en pacientes pediátricos con cáncer mejora significativamente la calidad de vida. La combinación de estrategias farmacológicas y no farmacológicas demuestra ser eficaz en el control de síntomas, mientras que el apoyo emocional y social contribuye al bienestar general del paciente y su familia.

We reviewed the impact of telehealth videoconferencing clinics on outcomes of care in pediatric patients with type 1 diabetes in rural Oregon. We performed a chart review as well as the review of patient satisfaction questionnaires from 27 patients seen in the first year of the program. The number of yearly visits to diabetes clinic increased from average 1.5 to 2.7, which was statistically significant (p < 0.0001). Glycemic control remained stable, and there was no difference in the amount of emergency department visits or hospitalizations related to diabetes. Patients expressed high satisfaction with the service and majority considered it equal to in-person visits. We conclude that telehealth videoconferencing visits have the potential to improve care in pediatric diabetes patients, particularly the patients living in areas distant from subspecialty centers.

Commentary Hamilton et al. have written an article that might be summarized as a disruptive challenge to the accepted perspective that all septic arthritis is the same and that the risk profile for adverse outcomes is equal, irrespective of osseous involvement. Their article, entitled “Children with Primary Septic Arthritis Have a Markedly Lower Risk of Adverse Outcomes Than Those with Contiguous Osteomyelitis,” provides clear data that the traditional approach to treating all septic arthritis equally is an antiquated abstraction. In their article, the authors have clearly demonstrated that there is a difference between primary septic arthritis and septic arthritis with contiguous osteomyelitis, a belief long suspected by those who regularly manage these patients. Hamilton et al. showed higher rates of bacteremia, longer hospitalizations with increased use of intensive care resources, and an increased risk of complications in pediatric patients who have a combination of septic arthritis and osteomyelitis. These considerations are pertinent to all physicians who treat these children, including both orthopaedic surgeons and pediatric specialists. The greatest effect of these data is the change that they bring to the classical approach to this condition. As the consequences of undertreatment of septic arthritis with contiguous osteomyelitis can be as severe as permanent and irreversible joint damage, it is arguable that the algorithm for the treatment of children with a suspected septic joint should now always include magnetic resonance imaging (MRI). At our institution, we previously adopted the practice of performing a screening MRI examination for the majority of patients with suspected septic hips on the basis that treatment decision-making would be altered if either osteomyelitis or an abscess was present, but scant data supported our protocol. The article by Hamilton et al. confirms the importance of MRI screening and demonstrates that the identification of osteomyelitis should trigger a different treatment protocol than that used for patients in whom osteomyelitis is not detected. Specifically, patients with osteomyelitis might benefit from care by a multidisciplinary team with a more aggressive medical and surgical approach. These changes in the approach to treatment do come with an increase demand for resources and thus cost. Institutions committed to the care of pediatric orthopaedic patients will need to consider topics such as timely access to MRI, particularly sedated MRI, as well the availability of pediatric infectious specialists and pediatric orthopaedists. I would assume that, when these increased costs are compared with the potential savings that can be achieved by decreasing length of stay, reducing overall complications, and avoiding the long-term consequences, the costs are more than justifiable. A future analysis of the cost-benefit ratio also may serve to energize a larger conversation around whether these children would be better served by receiving definitive treatment in a tertiary care center. In summary, this article will have a major impact on the care of pediatric patients with septic joints and should be mandatory reading for anyone involved in the study or treatment of this pediatric pathology. I anticipate that it will become accepted as a key article on this topic.

A Screening Tool for Addressing the Psychiatric Needs of the Pediatric Patient in the Emergency Department

Narrative medicine is an approach centered on patients' experiences and their illness stories. Its application in pediatric population warrants further research. This study aims to overview (1) the application of narrative medicine in pediatric medical education and (2) the implementation of narrative medicine in pediatric patient care. Searches were conducted in bibliographic databases (Cochrane Library, ClinicalTrials.gov, EBSCOhost, Embase, MedEdPORTAL, Ovid, PubMed, and Web of Science) without date or language restrictions. Researchers independently screened articles, charted data, and performed data synthesis. Educational intervention studies were evaluated with Kirkpatrick Scale, and Mixed Methods Appraisal Tool was used for methodological quality assessment of all studies. Forty-one articles met our criteria: 17 focused on the application of narrative medicine in pediatric medical education and 24 on its implementation in pediatric patient care. Educational interventions indicated general satisfaction, with reported improvements in empathy, reflection, patient understanding, and professional development. In patient care settings, narrative medicine provided a safe space for story sharing, enhancing emotional, relational, and social connections, and promoting patient- and family-centered care. This review highlights the translation of narrative medicine from educational interventions to clinical practice in pediatric settings. Although more robust research is required, existing evidence supports narrative medicine's potential to foster authentic engagement with patients and caregivers and enhance the quality of pediatric care across various conditions and developmental stages.

Evidence-based practice recommendations for infection prevention in pediatric sickle cell patients: Interventions for the primary care provider.

Is HCFA's reimbursement policy controlling quality of care for end-stage renal disease patients?