There is considerable practice variation nationally for using high-flow nasal cannula (HFNC) to treat hospitalized children with bronchiolitis, despite an abundance of literature supporting specific practices. We developed recommendations for using HFNC based on available evidence and expert opinion. Following the Research and Development (RAND)/University of California, Los Angeles Appropriateness Method, we conducted an exhaustive literature search for studies regarding the use of HFNC in bronchiolitis and drafted proposed use recommendations based on these findings. We convened an expert panel composed of nominees from national professional organizations with a range of professions (nursing, respiratory therapy, medicine) and clinical expertise (intensive care, emergency medicine, hospital-based care). Panelists rated recommendations for appropriateness and necessity in 3 sequential rating sessions and a moderated meeting. The 15-member panel evaluated 60 recommendations for the initiation, reassessment, escalation, and de-escalation of HFNC in bronchiolitis. The panel reached agreement on the appropriateness of HFNC for 52 of 60 recommendations and on necessity for 46 of 52. The panel agreed with practices that may curtail HFNC use, including initiating HFNC only for refractory hypoxemia or impending respiratory failure, initiating HFNC at flow rates of 1.5 to 2L/kg/min, and discontinuing HFNC once a patient is stable on fraction of inspired oxygen of 0.21 for 1-4 hours. A national expert panel agreed on the appropriateness and necessity of parameters for HFNC use in bronchiolitis. These recommendations allow for standardization of practice that may optimize outcomes and curb indiscriminate use of this respiratory support modality.

Pediatric emergency transfers (ETs), unplanned intensive care unit (ICU) transfers in which a child needs intubation, vasopressor initiation, or at least 60mL/kg fluid resuscitation within 1 hour, are associated with longer stays and higher mortality, yet their financial burden is unknown. Thus, we compared post-transfer financial charges for ETs vs non-ETs. We conducted a retrospective cohort study of 2034 ICU transfers between 2015 and 2019 at a freestanding children's hospital. We compared charges between ETs and non-ETs, including aggregate post-transfer ICU charges (transfer through ICU discharge), aggregate total post-transfer hospital charges (transfer through 100days post-transfer), and average daily post-transfer charges over the first 100days. Charge comparisons were adjusted for age, presence of complex chronic conditions, pretransfer length of stay, originating service, and deterioration type using regression models with generalized estimating equations. Compared to non-ETs, ETs had higher unadjusted post-transfer charges (ICU: 108% [95% CI 51-188], P < .01; total: 91% [95% CI 50-143], P < .01; daily: 61% [95% CI 35-91], P < .01). After adjustment, ETs remained associated with higher post-transfer charges (ICU: 65% [95% CI 22-123], P < .01); total: 49% [95% CI 17-90], P < .01; daily: 20% [95% CI 3-98], P = .02). ET-associated post-transfer charge increases varied significantly by originating service (general pediatrics: 104% [95% CI 30-221] vs surgical services: -19% [95% CI -55 to 47], P < .01) and deterioration type (respiratory: 177% [52%-407%] vs circulatory: 2% [-28% to 47%], P < .01). ETs are associated with significantly higher post-transfer charges for hospitalized children. This financial impact highlights the economic imperative, alongside clinical benefits, for investing in systems aimed at preventing delayed escalation and reducing ETs.

Approximately 1 in 10 children admitted to a hospital experience an adverse event, and of these events, approximately 44% can be considered to be preventable. It has been shown that focusing on family- and patient-centered care can improve both the quality of care and reduce harm. Little has been published about the perspectives of families regarding their roles in safety. The purpose of this study was to gain a deeper understanding of family experiences and priorities regarding their child's safety while in the hospital. Our team conducted semistructured interviews among caregivers in either a tertiary pediatric hospital or the pediatric unit of a general hospital to explore perceptions and experiences regarding pediatric patient safety during their hospital stay. Purposive sampling was used to promote the inclusion of families who differed by experience with past hospitalizations, complexity of child disease status, family structure, and culture. All semistructured interviews were conducted virtually and transcribed verbatim. Transcripts were analyzed using emergent thematic analysis. Twenty-five interviews were conducted, from which 2 primary domains emerged: (1) Safety Climate, which describes elements of the in-hospital environment that contribute to both physical and psychological safety such as protective policy/procedures related to risk mitigation, staff behaviors and attitudes, collaboration with families and information sharing, and respect for patient dignity and family inclusion in care; and (2) Family Integration and Future Directions, which describes caregivers' preference for accessible and inclusive channels and pathways to both learn about safety and report safety concerns. Caregivers of pediatric patients value family integration into patient safety and conceptualize safety in a manner that extends beyond freedom from harm. Staff attitudes and behaviors are strong contributors to a feeling of safety. This knowledge can provide a foundation for future codesign of strategies to improve patient and family partnership in safety.

Health care environments pose risks to both patients and care providers. This study investigates unit working conditions potentially impacting patient and provider safety concurrently to identify common risk factors for targeted interventions. Zero-inflated negative binomial models analyzed associations between select working conditions (eg, overtime, patient census) and patient/employee safety event rates. Multivariable regression models explored adjusted effects. Patient and employee safety event rates showed little correlation, with units having higher rates in one category often showing lower rates in the other. Significant associations were found between safety events and select working conditions; however, results were inconsistent across indicators and did not apply uniformly to both safety event types. Although patient and employee safety event rates were not correlated, evidence suggests common factors (unit group, registered nurse vacancy) jointly influence both outcomes. Further research on specific safety outcomes may reveal more causal associations.

Objective: Data exploring family-centered rounds (FCR) participation for caregivers who prefer a language other than English (LOE) are limited. We sought to characterize baseline rates of LOE-preferring caregiver FCR participation and reasons for not participating, as part of the current state analysis for a QI initiative.Methods: From July 1, 2023 to April 19, 2024, rounding data were recorded, including caregiver presence at bedside and caregiver participation in rounds, for patients admitted to General Pediatrics resident teams at a free-standing children's hospital. For LOE-preferring caregivers, we documented reasons for not joining rounds. We used logistic regression to compare FCR participation rates by preferred language and team; we utilized statistical process control p-charts to visualize participation over time.Results: Data were recorded for 7586 rounding encounters. This included 6781 encounters with English-preferring caregivers and 805 encounters with LOE-preferring caregivers, representing 231 patients with LOE-preferring caregivers. LOE-preferring (70.3%, n=566) and English-preferring (69.7%, n=4725) caregivers were present at bedside with equal frequency. Of caregivers present at bedside, LOE-preferring caregivers participated in 55.6% (n=315) of rounding encounters compared to 88.1% (n=4165) for English-preferring caregivers (P>0.001). The most common reason LOE-preferring caregivers did not participate in FCR was not being invited to join (82%, n=251). LOE-preferring caregiver participation varied over time (27% to 81%), by care team (39% to 91%) and individual LOE (27% to 83%).Conclusions: LOE-preferring caregivers participated in FCR less often than English-preferring caregivers despite similar bedside presence, largely because they were not invited to join. Identifying opportunities to improve LOE-preferring caregiver participation in FCR is essential to ensure the provision of equitable care.

Suicidal thoughts and behaviors (STBs) among pre-adolescents are increasing at alarming rates in the United States, with notable differences based on race, ethnicity, and sex, but little is known about nonfatal STBs in the group. We conducted a retrospective analysis of STB-related encounters among youth aged 6 through 12 using nationally representative US hospital data from 2020 to 2022, drawn from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample and National Inpatient Sample. Demographic and clinical characteristics were analyzed, as were type of STB (suicidal ideation, intentional overdose, asphyxiation, etc), classified using International Classification of Diseases, Tenth Revision diagnosis codes. National-level census denominators were used to calculate trends in rates of STB-related encounters as well as national and regional rates by racial/ethnic and sex subgroups. The majority of patients with STB (78.9%) had a code indicating only suicidal ideation as the reason for the encounter. Girls were 2.10 times more likely than boys to have an ED encounter for any STB (95% CI 2.06-2.14) and were 9.14 times more likely than boys to have an ED encounter for prescription drug overdose (95% CI 8.31-10.06). Over the 3-year study period, there were increasing trends in encounter rates for all groups, but the largest increases were seen among minoritized girls. There is an urgent need for a safety net of care so that caregivers of children with suicide risk have options other than the hospital for acute treatment of suicidal ideation and behaviors. Culturally responsive services are critical to addressing this public health crisis.

Asthma exacerbations are a leading cause of pediatric hospitalization, and systemic corticosteroids are a mainstay of inpatient treatment. This study describes hospital-level variability and trends in systemic corticosteroid prescribing during acute asthma exacerbation hospitalizations and examines hospital-level associations between prescribed corticosteroid and hospitalization outcomes. This retrospective cross-sectional study used the Pediatric Health Information System database to examine encounters of patients aged 2 to 18years who were hospitalized with an acute asthma exacerbation between January 1, 2016, and December 31, 2023 and were administered dexamethasone, prednisone, prednisolone, or methylprednisolone. We analyzed trends and hospital-level variation in systemic corticosteroid prescribing. We used generalized estimating equations to analyze the association of annual hospital-level dexamethasone use with hospitalization outcomes-length of stay, ED revisit, and readmission rates, with models adjusted for relevant clinical and demographic factors. We identified 122 856 asthma hospitalizations across 38 children's hospitals. From 2016 to 2023, the proportion of hospital-level dexamethasone use increased from 42% to 77%. The proportion of hospitals prescribing dexamethasone for over 80% of hospital encounters rose from 18% in 2016 to 66% in 2023. There was no difference in hospitalization outcomes based on annual hospital-level dexamethasone use, including a subanalysis also based on annual hospital-level dexamethasone use focusing on exclusive dexamethasone or exclusive prednisone/prednisolone use (P > .05). Dexamethasone use during asthma hospitalizations increased during the study period, without differences in hospitalization outcomes between hospitals that used a higher proportion of dexamethasone vs those that used less.

Pediatric neuroinflammatory disorders (NIDs) pose significant health and financial challenges, yet comprehensive cost estimates are lacking. These conditions likely contribute disproportionately to health care expenditures. To assess the burden of NID-related hospitalizations, we analyzed Texas hospital administrative records. We used the Texas Health Care Information Collection Inpatient Public Use Data File (2016-2023) to explore drivers of inpatient resource use for NIDs. Pediatric hospitalizations with a primary diagnosis of acute disseminated encephalomyelitis, encephalitis and encephalomyelitis (E/EM), multiple sclerosis/neuromyelitis optica spectrum disorders, and other demyelinating disorders, or acute transverse myelitis and other myelitis were included. Charges were converted to costs using hospital-level annual average cost-to-charge ratios and then inflated to 2023 costs. Statistical analysis was implemented to predict the likelihood of having a high-cost or a longer length of stay (LOS) hospitalization and a hospitalization that involved intensive care. There were 2155 hospitalizations involving pediatric patients with a primary diagnosis of NIDs. The most common diagnoses were E/EM. The median total cost of these hospitalizations was $31 365.49, with a median LOS of 6days. More than half (59.1%) required intensive care unit (ICU) admission and were associated with a higher cost. After adjusting for patient and facility characteristics, the primary diagnostic group remained a significant independent predictor of whether hospitalization was classified as high-cost or long-LOS or involved an ICU stay. These findings align with clinical observations, highlighting the significant burden of NIDs, which often require longer hospital stays, intensive care, and higher costs compared with most pediatric conditions.

To describe clinical practice patterns in diagnostic testing, antibiotic treatment, hospitalization, subspecialty consultation, and discharge recommendations for children with preseptal and orbital cellulitis across Canadian hospitals. A cross-sectional survey of pediatric hospitalists and pediatric emergency department (ED) physicians was conducted. The survey was distributed through the Canadian Pediatric Inpatient Research Network and completed by hospital representatives. Site-level clinical management specific to clinician was assessed. Data were analyzed descriptively. Of 40 hospitals contacted (17 children's and 23 community hospitals), 32 responded (80%; 13 children's hospitals, 19 community hospitals). The most ordered tests in the ED were complete blood count (81.9%) and C-reactive protein (CRP; 81.9%). When not ordered in the ED, 20 (62.5%) pediatric inpatient services ordered CRP and 4 (12.5%) ordered erythrocyte sedimentation rate. For admitted children, computed tomography scans were ordered always or frequently by 46.2% of children's hospital pediatricians and 5.3% of community hospital pediatricians. Ophthalmology (n = 11, 84.6%), otolaryngology (n = 9, 69.2%), and infectious diseases (n = 6, 46.2%) were frequently consulted at children's hospitals. Children with preseptal cellulitis not requiring admission were usually discharged home on oral cephalexin, whereas 2 sites recommended intravenous (IV) ceftriaxone. All children admitted with orbital cellulitis received IV antibiotics initially, most commonly a third-generation cephalosporin with antianerobic and antistaphylococcal agents or a third-generation cephalosporin with an antistaphylococcal agent. There is limited consensus on diagnostic tests, subspeciality consultation, and empirical antibiotic therapy for preseptal and orbital cellulitis. This survey provides insight into health system-level usage that highlights the need to develop a clinical practice guideline to help standardize management.