Although contaminated blood cultures are known to result in billions of dollars in annual health care costs in the United States due to excess health care utilization and antibiotic exposure, the burden in pediatrics is not well described. Retrospective cohort study of 128 524 blood cultures obtained from 2010 to 2022 in outpatient and hospital settings in a multicenter health care system. Cultures with commensal organisms were considered contaminated after excluding patients with high-risk conditions, including immunodeficiencies, malignancy, and indwelling catheters. Health care utilization and cost assessment were analyzed and compared between patients with contaminated blood cultures and patients with true positive or negative blood cultures. Contaminated blood cultures resulted in 15-fold (odds ratio [OR] = 15.10; 95% CI: 13.50-17.00) higher odds of emergency department (ED) visits, 6-fold (OR = 5.71; 95% CI: 4.63-7.05) higher odds of admissions, and 32% longer length of stay (risk ratio = 1.32; 95% CI: 1.26-1.39) compared with age-matched noncontaminated negative blood cultures. This resulted in approximately $980 in ED costs per contaminant for outpatients and $2500 in hospital costs per contaminant for inpatients, a total of $1.5 million in ED costs over the study. Patients with contaminated cultures received more antibiotics and underwent more blood draws than patients with negative blood cultures. Pediatric blood culture contamination results in excess reutilization with significant economic costs and impact on patients.

We sought to describe order set designs implemented by hospitals participating in the national Standardization of Fluids in Inpatient Settings (SOFI) trial and drivers of design decisions. We explored associations between order set design and the SOFI primary outcome of guideline-concordant exclusive isotonic intravenous fluid (IVF) use. We surveyed site leaders to characterize order set modifications and understand drivers. We used applied thematic analysis to analyze qualitative data. We combined quantitative survey data with SOFI data to evaluate associations between order set changes and guideline adherence using linear mixed-effects regression models. One hundred site leaders were surveyed twice during the SOFI trial (92% response rate). Order set modifications were predominantly made to admission order sets and included listing isotonic IVF first with no preselected order (44%), removing hypotonic fluid options (61%), and preselecting isotonic IVF by default (39%). Drivers of order set design included facilitating personalized care, navigating information technology limitations, preserving clinician autonomy, managing order set ownership, and seeking consensus. Order sets listing isotonic IVF first but without preselecting this option were associated with an additional increase of 3.5% (95% CI 1.1%-5.9%; P = .005) in exclusive isotonic IVF use above the aggregate SOFI intervention effect. We identified drivers of order set design and found that listing guideline-concordant orders first in order sets was associated with increased guideline adherence. Future quality improvement efforts may benefit from this approach, which increases clinician efficiency, maintains autonomy, and promotes order set applicability to multiple patient populations.

Patient families using languages other than English (LOE) face communication challenges. Family-centered rounds (FCR), the gold standard in inpatient pediatric care, are understudied in this population. To (1) describe medical team behaviors during FCR with pediatric families who use LOE, (2) assess the quality of FCR and interpreter partnership and their association with interpreter partnership behaviors, and (3) examine associations between interpreter partnership behaviors and FCR duration. This prospective observational study was conducted at a quaternary children's hospital. From March to October 2024, we observed general pediatric teams during FCR with families who spoke LOE using a standardized observer form. The independent variables were patient demographics and team behaviors, including interpretation modes (in-person, video, ad hoc) and methods (continuous interpretation; round without caregiver, interpret summary). The primary outcomes were quality scores for FCR (Agency of Health Research and Quality checklist) and interpreter partnership (Faculty Observer Rating Scale). The secondary outcome was FCR duration. Descriptive statistics and adjusted linear regression models were used. Of 66 observed FCRs, 88% used interpretation. The majority used in-person interpretation (57%) and "round without caregiver, interpret summary" (42%). Interpretation use was associated with higher FCR quality (β = 2.06; P = .001). Ad hoc interpretation was associated with lower FCR quality (β = -1.37; P = .01) and interpreter partnership quality (β = -13.59; P = .001). No differences were found in FCR duration between interpretation modes, or between "continuous interpretation" and "round without caregiver, interpret summary" (P > .05). Interpretation use was associated with higher FCR quality. There were no differences in FCR duration by interpretation mode or methods, supporting the feasibility of continuous interpretation.

Patients and families who use a language other than English (LOE) for health care communication face heightened risks for poor outcomes due to structural language barriers. Although interpreter services are increasingly available, considerable variability remains in how language access is operationalized. This study aimed to examine interpreter service infrastructure, processes for identifying language needs, and barriers to equitable care for hospitalized pediatric patients who use LOEs in Canada. We conducted a cross-sectional survey of clinical leaders from pediatric inpatient units across Canada. The survey explored interpreter service availability, language identification processes, staff training, and perceived barriers to effective communication. Quantitative data were analyzed descriptively, and open-ended responses were examined qualitatively using thematic analysis. Thirty-six tertiary academic and community hospitals participated. Only 40% of respondent hospitals reported a formal process for identifying language needs at admission, and most lacked standardized documentation in electronic medical records. Key identified barriers to optimal language support for patients and families, identified from both quantitative and open-ended responses, included time constraints, inconsistent service availability, and situations in which families declined interpreter support, potentially due to previous experiences of stigma or mistrust. Participants recommended improvements, including improved identification and documentation of patients needing interpreters, increased interpreter availability, and expanded staff training. There are persistent gaps in the equitable provision of interpreter services and supports for families who use LOEs in Canadian pediatric hospitals. To ensure that language access becomes a foundational component of safe family-centered care, interpreter services must be embedded into clinical workflows, supported by institutional infrastructure, and implemented in ways that foster trust and relational safety.

The objective of this study was to describe potential differences caused by race, ethnicity, and socioeconomic status in admission criteria and inpatient treatment of children with a diagnosis of growth faltering (GF). A retrospective medical record review was conducted of children aged 1 to 24months admitted to a tertiary children's hospital with a diagnosis of GF from January 2012 to January 2022. Demographic data, growth parameters, and inpatient treatment (ie,laboratory tests, consultations, interventions) were extracted from the electronic medical record. Data were analyzed via generalized estimating equations using logit link. The study population (n = 982 encounters, n = 890 unique patients) was predominantly white (69%) and Medicaid recipients (60%). Black patients had the highest area deprivation index (ADI) score (7.0; P < .001). Black patients had lower admission (-3.1) and discharge (-2.7) weight-for-age z scores (WFAZ) compared with white patients (-2.5 and -2.0, respectively; P < .001) with no difference in median weight change or length of stay. Difference in admission WFAZ was associated with increased rates of social work consultations (odds ratio [OR] 1.76; P = .001) and Child Protective Services (CPS) referrals (OR 1.89; P = .008) for Black patients compared with white patients. White patients had higher lactation consultation rates (25%) compared with Black patients (13%; P = .002), attributed to higher breastfeeding rates in white patients. This study identified differences in consultations based on race and socioeconomic status for children admitted with GF, related to Black patients admitted at lower WFAZ and thereby with more severe GF. Further study is needed to understand and address factors contributing to this difference to better elucidate disparities in care.

The objective of this study was to assess the relationship between experiences of past discrimination (ie,discrimination) and caregiver participatory behaviors during family-centered rounds (FCR). We conducted a mixed-methods cross-sectional study investigating the association between discrimination among Black and Latino(a/e) caregivers and communication on FCR from February 2024 to April 2025. FCR were audio-recorded, and caregivers completed surveys that collected demographics, ratings of interpersonal processes of care (IPC), and discrimination. Discrimination was measured using an abbreviated validated Experiences of Discrimination instrument. We stratified caregivers into 3 groups: no discrimination, discrimination in health care, and discrimination outside of health care. Staff coded the type and content of caregiver participatory behaviors. Kruskal-Wallis testing compared survey and coded measures among the 3 groups. We recorded, transcribed, and coded FCR with 56 Black and Latino(a/e) caregivers; 30 (54%) reported no discrimination, 18 (32%) reported discrimination outside of health care, and 8 (14%) reported discrimination in health care. Caregivers with discrimination in health care asked a higher median (IQR) number of questions per interaction (5 [2, 8]) compared with those with no discrimination (1 [0, 3]) and discrimination outside of health care (1.5 [1, 4]; P = .03). They made more assertive statements (4.5 [3.5, 5.5]) compared with those with no discrimination (2 [0, 2]) and discrimination outside of health care (0.5 [0-2]; P < .001). Other significant associations included increased behaviors categorized as advocacy and seeking medical understanding. IPC ratings were significantly lower in the interpersonal style domain for these caregivers. Discrimination in health care is associated with increased caregiver participatory behaviors on FCR. These behaviors, which may represent increased caregiver vigilance, support clinician use of trauma-informed communication.

Children with medical complexity (CMC) are a heterogeneous population with chronic multisystem conditions, high utilization, and poor outcomes. While large administrative datasets (eg, Pediatric Health Information [PHIS], Kids' Inpatient Database [KID], Medicaid claims) have characterized these populations, they often lack clinical detail. We evaluated the performance of the Pediatric Complex Chronic Condition System version 3 (CCCv3) in Epic Cosmos (Epic Systems Corp), a national deidentified electronic health record dataset with potential to expand CMC research. We conducted a retrospective cohort study of pediatric hospitalizations (patients ≤18years old) in Cosmos between 2015 and 2025. CMC were identified using CCCv3 applied to admission, discharge, billing, and problem list diagnoses. We described complex chronic condition (CCC) distribution, hospitalization burden, and demographics. Associations between CCC count and outcomes were measured using negative binomial regression for length of stay (LOS) and modified Poisson regression for in-hospital mortality. Among 4 524 010 admissions, 43.3% of patients had at least 1 CCC, accounting for 55.8% of hospitalizations and 69.0% of hospital days. Patients with 4 or more CCCs represented 4.4% of the cohort but accounted for 14.3% of admissions and 27.2% of hospital days. Each additional CCC was associated with a 21% increase in LOS (incidence risk ratio, 1.21; P < .001). Mortality risk increased stepwise with each additional CCC. Compared with administrative datasets, Cosmos identified a higher absolute prevalence of CCCs but preserved relative trends in utilization and outcomes. CCCv3 applied in Cosmos stratifies patient complexity in patterns consistent with prior administrative studies, despite higher absolute prevalence. Recognizing this classification system can be used in Cosmos adds a clinically rich platform available for advancing pediatric research and clinical decision support.

Secure text messaging systems (STMS) have transformed the way health care clinicians communicate. Although the benefits of rapid and easy communication among team members were anticipated, the volume of messages was less predictable. This study sought to quantify the volume of messages accessed (sent and received) by a pediatric hospitalist during a clinical shift. Messages accessed by pediatric hospitalists during their shifts from November 16, 2024 through March 9, 2025 were counted and grouped according to shift (day 0700-1700, night 1701-0659). One daytime hospitalist had the additional role of triaging admission, consult, and transfer calls. Residents were listed as first contact for admitted patients. Daily census was tracked. Negative binomial regression was used to assess the relationship of message volume with different shifts and census. A daytime pediatric hospitalist without triage responsibilities accessed a median of 50 (IQR: 26-95) messages per day, which was significantly less than with triage (109 [78-161] messages/d; P < .0001). The nighttime hospitalist accessed a median of 77 (51-133) messages per day. There was a positive association with morning census and volume of daytime messages (P = .0014). Overall, hospitalists received 34% more messages than they sent per day (P = .008). Pediatric hospitalists accessed a high volume of STMS despite not being the assigned first contact. Higher morning census and triaging calls adds a significant volume of messages. Frequent messages may lead to alert fatigue, burnout, and inefficiency. Future steps include efforts to optimize the volume of messages and limit unnecessary distractions from patient care.

Injured children and youth with special health care needs (CYSHCN) can present competing priorities for prehospital and hospital care. Clinicians must balance the potential impact of chronic conditions-such as attention-deficit/hyperactivity disorder, autism, diabetes, or depression-with concerns about acute injury treatment for CYSHCN. The objective of this study is to identify the organizational and macro-level challenges and opportunities that clinicians face when caring for injured CYSHCN in acute care settings. We conducted qualitative interviews (N = 36) with prehospital and hospital clinicians that serve the level 1 trauma centers in 1 metropolitan region in the Northeastern United States and treat patients aged younger than 19years. The interviews were recorded, transcribed, and analyzed through rapid analysis to identify themes as well as suggestions for recommendations to improve care. We identified 4 themes that corresponded with organization-level factors: multidisciplinary care coordination; staffing and skill alignment; protocols, policies, and practices in conflict with patient care; and competing organizational needs. Additionally, clinicians listed myriad inter-organizational, regulatory, and societal factors that varied based on the specific context. Five recommendations are presented based on the identified themes, grounded in improving care quality for CYSHCN: developing protocols to enable coordination and follow-up across disciplines; ensuring that staff are trained to handle dual priorities; engaging trained staff and resources; reviewing organizational protocols, policies, and practices to better accommodate CYSHCN and their families; and galvanizing organizational buy-in for change. In a future study, we will engage family caregivers to inform these recommendations.