Academic Children's Hospital Research Articles

Anesthetic management for aspiration thrombectomy using the Penumbra Indigo System® in pediatric patients with congenital heart disease

ObjectivesDescribe clinical characteristics and outcomes including transfusion requirements of pediatric patients with congenital heart disease undergoing aspiration thrombectomy DesignRetrospective chart review SettingQuaternary academic children's hospital ParticipantsPatients < 18yrs with congenital heart disease undergoing aspiration thrombectomy from November 2017-February 2022. Measurements and main results13 patients underwent mechanical thrombectomy with the Penumbra Indigo System®. Median age was 3.8 years and median weight was 15.2kg. Seven patients had palliated single ventricle and 6 had biventricular circulation. Nine patients were receiving ICU care pre-procedure and 12 required ICU care post-procedure. Indications for thrombectomy included systemic venous thrombus (n=7), pulmonary arterial thrombus (n=3), systemic arterial thrombus (n=2), and systemic to pulmonary shunt occlusion (n=1). Median estimated blood loss was 7.7ml/kg (interquartile range 1.4ml/kg-15.8ml/kg, range 0.5ml/kg-51.5ml/kg). Seven patients required intraoperative transfusion of pRBCs (n=4), FFP (n=2), platelets (n=3), and/or cryoprecipitate (n=1). In those requiring transfusion, median transfusion volume was 22ml/kg (interquartile range 15.5ml/kg-76.5ml/kg, range 9.3ml/kg-132.8ml/kg). Thrombectomy was successful in 8 of 13 patients, although 3 experienced recurrent thrombosis. ConclusionsMechanical aspiration thrombectomy is increasingly used to treat critically ill pediatric patients and presents unique anesthetic considerations particularly related to the need for volume and blood product resuscitation

Diagnostic Safety: Needs Assessment and Informed Curriculum at an Academic Children's Hospital.

Diagnostic excellence is central to healthcare quality and safety. Prior literature identified a lack of psychological safety and time as barriers to diagnostic reasoning education. We performed a needs assessment to inform the development of diagnostic safety education. To evaluate existing educational programming and identify opportunities for content delivery, surveys were emailed to 155 interprofessional educational leaders and 627 clinicians at our hospital. Educational leaders and learners were invited to participate in focus groups to further explore beliefs, perceptions, and recommendations about diagnostic reasoning. The study team analyzed data using directed content analysis to identify themes. Of the 57 education leaders who responded to our survey, only 2 (5%) reported having formal training on diagnostic reasoning in their respective departments. The learner survey had a response rate of 47% (293/627). Learners expressed discomfort discussing diagnostic uncertainty and preferred case-based discussions and bedside learning as avenues for learning about the topic. Focus groups, including 7 educators and 16 learners, identified the following as necessary precursors to effective teaching about diagnostic safety: (1) faculty development, (2) institutional culture change, and (3) improved reporting of missed diagnoses. Participants preferred mandatory sessions integrated into existing educational programs. Our needs assessment identified a broad interest in education regarding medical diagnosis and potential barriers to implementation. Respondents highlighted the need to develop communication skills regarding diagnostic errors and uncertainty across professions and care areas. Study findings informed a pilot diagnostic reasoning curriculum for faculty and trainees.

Pediatric Early Warning Scores Before Rapid Response Poorly Predict Intensive Care Unit Transfers.

The Pediatric Early Warning Score (PEWS) is a clinical tool used to identify children at risk for clinical deterioration, but its utility remains debated, particularly in high-resource settings. Our objective with this study was to assess the predictive performance of the PEWS for unplanned PICU transfers after pediatric rapid response team (RRT) activation. A retrospective cohort study at a tertiary care academic children's hospital included all hospitalized patients up to 21 years old who had RRT activations between August 2021 and July 2022. Demographic and clinical data, the primary reason for RRT activation, and the modified Brighton PEWS were collected. The primary outcome was PICU transfer following RRT activation, and the secondary outcome was rapid escalation of care within 4 hours after RRT activation. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were calculated at multiple PEWS thresholds. Of 297 RRT activations in 244 patients, 183 (63%) resulted in a PICU transfer, 75% of which were due to respiratory concerns. The PEWS was recorded in 89% of RRT activations within the preceding 4 hours. There was no significant difference in the PEWS between patients with or without PICU transfer or rapid escalation of care. The sensitivity, specificity, and AUROC of PEWS for predicting PICU transfer or rapid escalation of care were low (AUROC 0.495-0.613). PEWS within 4 hours before RRT activation was a poor predictor of PICU transfer or rapid escalation care. Further work is needed to develop a more sensitive and specific tool.

Worth the Pain? Comparing Pain Scores in Primary Furlow Palatoplasty With and Without Buccal Flap Augmentation.

Pain following primary palatoplasty can adversely affect nutritional and quality of life following primary palatoplasty. The incorporation of buccal flaps during primary cleft palate (CP) repair provides additional tissue to reduce the risk of velopharyngeal insufficiency, though the additional donor site may alter pain levels in the postoperative period. This study sought to compare postoperative pain levels in patients undergoing primary CP repair with or without buccal flaps. A single-institution, retrospective cohort study. An academic children's hospital with an affiliated comprehensive cleft care team. Patients age 18 months or less with cleft palate undergoing primary palatoplasty from 2016 to 2021 were included. Patients were stratified by the number of buccal flaps utilized during repair. Primary outcome was 24-h postoperative pain score, measured using the FLACC pain scale. Secondary outcome was 24-h postoperative narcotic use, measured in morphine milligram equivalents (MME). A total of 106 patients (53 without buccal flaps, 53 with 1 + buccal flaps) were included. There was no significant difference in postoperative pain scores between the groups (p > 0.9). Both groups had similar postoperative narcotic utilization (p = 0.8). This study demonstrates no significant difference in postoperative pain levels or narcotic utilization between patients undergoing primary Furlow palatoplasty with or without buccal flaps. This information can help address parental concerns regarding pain in the context of a larger donor site for patients undergoing primary palatoplasty with buccal flaps. Larger, multi-institutional randomized trials are needed to confirm these findings.

Retrospective evaluation of implementation of caring contacts for youth suicide prevention in an emergency department.

Caring Contacts are brief caring messages sent to patients with suicidal thoughts or behaviors after an emergency department (ED) visit or hospitalization, which may decrease subsequent suicide attempts. We aimed to retrospectively evaluate the implementation of Caring Contacts in a children's hospital ED. We conducted a retrospective observational study to evaluate the implementation of Caring Contacts within routine clinical care at an academic children's hospital ED from May 2020 to April 2023. Patients 5‒18 years old presenting for suicidal thoughts or behaviors were eligible to receive six handwritten cards with individualized caring messages, mailed over 12 months. We assessed enrollment rates (the percentage of patients offered Caring Contacts who agreed to receive them), fidelity to the intended schedule and card writer, return visits for suicidal ideation or behaviors while receiving Caring Contacts, and program costs. Of 627 encounters eligible for and offered Caring Contacts, 614 (98%) resulted in enrollment. Among instances of enrollment, 587 (96%) had cards sent per the intended schedule and 541 (88%) had cards written by the intended writer. A return ED visit for suicidal ideation or behaviors occurred for 168 (27%) during program participation. Costs per participant were $4.54 in materials and 0.9h of personnel time. In a children's hospital ED, Caring Contacts were feasible to implement with low costs and high fidelity to the intended schedule and card writer. Prospective studies are needed to assess Caring Contacts' effectiveness in reducing suicide risk among adolescents following an ED visit.

Cost-Benefit Analysis of a Pediatric ICU Sedation Weaning Protocol.

A risk stratified sedation weaning protocol improved patient outcomes in a pediatric intensive care unit (PICU). We sought to determine the protocol effect on medication costs. This was a retrospective observational cohort study in an academic tertiary care children's hospital PICU (2018-2020) comparing the cost when weaning benzodiazepine, alpha agonist, and/or opioid infusions in intubated children <18 years of age. There were 84 total sedation weaning instances (pre-protocol n = 41 and post-protocol n = 41); 2 patients had 2 encounters, 1 in each phase. The total cost (in 2022 United States Dollars) of sedation weaning was $400,328.87 ($15,994.44/kg) pre-protocol compared with $170,458.85 ($11,227.52/kg) post-protocol. The median cost of sedation wean per patient for pre-protocol patients was $3197.42 (IQR: $322.66-$12,643.29) and post-protocol patients was $1851.44 (IQR: $425.05-$5355.85; p = 0.275). A linear regression model estimated the expected cost of sedation wean for post-protocol patients to be $5173.20 lower than for pre-protocol patients of the same weight and overall drug risk (p = 0.036). The proportion of withdrawal symptoms in the pre-protocol patients (16%) was not significantly different from the proportion in the post-protocol patients (14%; p = 0.435). Implementation of a PICU sedation weaning protocol in a single-center conferred cost benefit without negatively impacting patient outcomes. A larger multicenter study would provide insight to the applicability to PICUs in varied settings with differing patient populations.

Calcium channel blockers and beta blockers in pediatric supraventricular tachycardia.

Supraventricular tachycardia (SVT) is a common pediatric arrhythmia. Beta blockers (BBs) and calcium channel blockers (CCBs) are used for treatment despite little data examining their use. We describe the prescriptive tendencies, efficacy, and tolerability of BBs and CCBs used in the treatment of pediatric SVT. This is a multicenter retrospective cohort study from three academic children's hospitals. Individuals aged 1-21 years at time of SVT diagnosis initiated on a BB or a CCB between 01/01/2010 and 12/31/2020 were included. Exclusion criteria were pre-excitation, ectopic atrial tachycardia, and hemodynamically significant heart disease. Demographic, comorbidity, symptomatology, and medication data were collected. Treatment success was defined using a composite data abstraction tool. Of 164 patients, 151 received a BB and 13 received a CCB. The success rate on the initial dosage was 46% for both BB and CCB; the success rate following dosage adjustments was also comparable for BBs (98/151, 65%) and CCBs (9/13, 69%). While 27 (18%) BB patients experienced intolerable side effects, no CCB patient did. Treatment with a BB or CCB was successful in half of patients. BBs were prescribed more frequently than CCBs but were associated with more side effects.

Correlation of Transthoracic Echocardiographic Estimates of Right Ventricular Pressure with Right Ventricular Pressure Measurements on Cardiac Catheterization in Children with Pulmonary Hypertension

ObjectivesEvaluate correlation of non-invasive echocardiographic estimates of right ventricular systolic pressure with measurements on cardiac catheterization in children with pulmonary hypertension DesignRetrospective chart review SettingQuaternary academic children's hospital ParticipantsPatients < 18yrs with a diagnosis of pulmonary hypertension and confirmatory cardiac catheterization from 2015-2018. Measurements and main resultsWe analyzed the correlation between measures of right ventricular systolic pressure using nonparametric Spearman rho (ρ) with statistical significance set at p<0.05. Results111 children with biventricular circulation, strictly defined pulmonary hypertension, and adequate tricuspid regurgitation on echocardiogram to estimate right ventricular systolic pressure using the modified Bernoulli equation. Median age and weight were 4.3 years and 14.4 kg. Median right ventricular systolic pressure estimated by tricuspid regurgitant velocity on echocardiography was 55 mmHg (IQR 45-75 mmHg) plus right atrial pressure. On cardiac catheterization, median right ventricular systolic pressure was 57 mmHg (IQR 46-75 mmHg). Echocardiographic estimates of right ventricular systolic pressure were moderately well correlated with right ventricular systolic pressure directly measured on catheterization (ρ=0.44, 95% CI 0.27-0.6, p<0.001) with a median difference of 4mmHg (IQR -10-17). Subgroup analysis revealed that echocardiography and catheterization measurements correlated well in children with suprasystemic right ventricular pressure on cardiac catheterization (ρ=0.75, 95% CI 0.51-0.99, p<0.001) although catheterization measurements were a median of 26 mmHg (IQR 12-31) higher than echocardiographic estimates in this subgroup. ConclusionsIn children with pulmonary hypertension, echocardiographic estimates of right ventricular pressure correlated moderately well with gold standard measurements by cardiac catheterization with stronger correlation in children with suprasystemic right ventricular pressures. This is reassuring for clinicians who must rely on echocardiography for risk stratification prior to anesthetizing children with pulmonary hypertension.

Drivers of Inpatient Subspecialty Consultation Among Pediatric Hospitalists: A Qualitative Study.

Inpatient subspecialty consultation is often medically necessary but in some cases may represent overuse. While pediatric consultation patterns have been described using observational data, qualitative methods may generate knowledge about contextual determinants of consultation behavior. Our objective was to understand how pediatric hospitalists make decisions about subspecialty consultation. This qualitative study took place at a large academic children's hospital as part of an explanatory sequential mixed-methods design (QUAN → qual). We conducted semistructured interviews with a purposive sample of previously identified high-consulting (top quartile) and low-consulting (bottom quartile) pediatric hospitalists. Interviews were conducted virtually, and audio recordings were transcribed. Two analysts coded transcripts using an integrated approach and established high interrater reliability (κ > 0.75). We organized findings using the Social Ecological Model. Participants (n = 12) included high-(n = 6) and low-(n = 6) consulting hospitalists. Our respondents identified considerations including patient characteristics, confidence in their own competence and that of their team, and perceived helpfulness of consultants. Participants viewed consultation requests as being strongly influenced by a desire to maintain relationships with families. Specific to this context, the hospital's elite reputation was believed to influence families to expect consultations. Other considerations included medicolegal risk, clinical pathways, and availability of secure text messaging to facilitate informal "curbside" conversations with subspecialists. Decision-making around pediatric subspecialty consultation is complex and influenced by factors unrelated to a patient's clinical need. Efforts to reduce low-value consultation must account for the social and organizational dynamics that promote consultation.

Pharmacokinetic Factors Associated With Early Meropenem Target Attainment in Pediatric Severe Sepsis.

To determine the frequency of early meropenem concentration target attainment (TA) in critically ill children with severe sepsis; to explore clinical, therapeutic, and pharmacokinetic factors associated with TA; and to assess how fluid resuscitation and volume status relate to early TA. Retrospective analysis of prospective observational cohort study. PICU in a single academic quaternary care children's hospital. Twenty-nine patients starting meropenem for severe sepsis (characterized as need for positive pressure ventilation, vasopressors, or ≥ 40 mL/kg bolused fluid), of which 17 were newly escalated to PICU level care. None. Concentration-time profiles were analyzed using modeling software employing opportunistic sampling, Bayesian estimation, and a population pharmacokinetic model. Time above four times minimum inhibitory concentration (T > 4×MIC), using the susceptibility breakpoint of 1 µg/mL, was determined for each patient over the first 24 hours of meropenem therapy, as well as individual clearance and volume of distribution (Vd) estimates. Twenty-one of 29 patients met a target of 40%T > MIC 4 μg/mL. Reaching TA, vs. not, was associated with lower meropenem clearance. We failed to identify a difference in Vd or an association between the TA group and age, weight, creatinine-based estimated glomerular filtration rate (eGFR), or the amount of fluid administered. eGFR was, however, negatively correlated with overall T > MIC. Eight of 29 pediatric patients with early severe sepsis did not meet the selected TA threshold within the first 24 hours of meropenem therapy. Higher clearance was associated with failure to meet targets. Identifying patients likely to have higher meropenem clearance could help with dosing regimens.

Female Leadership in Pediatric Ophthalmology: A Descriptive Analysis.

To examine female representation among current chiefs of pediatric ophthalmology services of academic medical centers and children's hospitals, as well as program directors of ophthalmology residency and pediatric ophthalmology fellowship programs in the United States. Data collection for this cross-sectional study occurred between December 2023 and February 2024, using publicly available sources to compile a list of academic medical centers and children's hospitals, as well as ophthalmology residency programs and pediatric ophthalmology fellowship programs that participated in the 2023-2024 San Francisco Match. Chi-squared analyses were performed using Excel 2021 software, where a P value less than .05 was considered statistically significant. Of the dedicated pediatric ophthalmology services across academic medical centers and children's hospitals in the United States, 38.3% (64/167) are led by a female chief. Female representation was greater at children's hospitals (40.0%, 36/90) than at academic medical centers (36.4%, 28/77), although no significant difference was observed (P = .69). Gender distribution was near equivalent at both academic training program levels, with slightly more female directors of fellowship programs (45.7%, 21/46) than ophthalmology residency programs (42.3%, 52/123) (P = .33). The authors report near equivalent female representation in the leadership of academic training programs at the residency and fellowship level. However, the proportion of female pediatric ophthalmology division chiefs lags behind the actual gender composition of the workforce. Given the increasing prevalence of female pediatric ophthalmologists, promotion of concordant representation in leadership is necessary to reflect the changing sociocultural landscape and to close the gender gap. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

Risk factors for adverse outcomes in children with diabetic ketoacidosis.

Develop a multivariable model to identify children with diabetic ketoacidosis (DKA) and/or hyperglycemic hyperosmolar state (HHS) at increased risk of adverse outcomes, and apply it to analyze adverse outcomes during and after the COVID-19 pandemic. Retrospective review of clinical data from 4565 admissions (4284 with DKA alone, 31 [0.7%] only HHS, 250 [5.4%] hyperosmolar DKA) to a large academic children's hospital from January 2010-June 2023. 2010-2019 data (N=3004) were used as a training dataset, and 2020-2021 (N=903) and 2022-2023 (N=658) data for validation. Death or intensive care unit stays >48 hours comprised a composite "Adverse Outcome" group. Risks for this composite outcome were assessed using generalized estimating equations. There were 47 admissions with Adverse Outcomes (1.5%) in 2010-2019, 46 (5.0%) in 2020-2021, and 16 (2.4%) in 2022-2023. Eight patients died (0.18%). Maximum serum glucose, initial pH and diagnosis of type 2 diabetes most strongly predicted Adverse Outcomes. The proportion of patients with type 2 diabetes was highest in 2020-2021. A multivariable model incorporating these factors had excellent discrimination (area under receiver operator characteristic curve [AUC] of 0.948) for the composite outcome in the training dataset, and similar predictive power (AUC 0.960 and 0.873) in the 2020-2021 and 2022-2023 validation datasets, respectively. In the full dataset, AUC for death was 0.984. Type 2 diabetes and severity of initial hyperglycemia and acidosis are independent risk factors for Adverse Outcomes, and explain the higher frequency of Adverse Outcomes during the COVID-19 pandemic. Risks decreased in January 2022-June 2023.

Critical Event Checklists for Simulated In-Hospital Dysrhythmias in Children with Heart Disease.

Children with heart disease are at increased risk of unstable dysrhythmias and in-hospital cardiac arrest (IHCA). Clinician adherence to lifesaving processes of care is an important contributor to improving patient outcomes. This study evaluated whether critical event checklists improve adherence to lifesaving processes during simulated acute events secondary to unstable dysrhythmias. A randomized controlled trial was conducted in a cardiac ward in a tertiary care, academic children's hospital. Unannounced simulated emergencies involving dysrhythmias in pediatric patients with underlying cardiac disease were conducted weekly. Responders were pediatric and anesthesiology residents, respiratory therapists, and bedside registered nurses. Six teams were randomized into two groups-three received checklists (intervention) and three did not (control). Each team participated in four simulated scenarios over a 4-week pediatric cardiology rotation. Participants received a brief slideshow presentation, which included a checklist orientation, at the start of their rotation. Simulations were video and audio recorded and those with three or more participants were included for analysis. The primary outcome was team adherence to lifesaving processes, expressed as the percentage of completed critical management steps. Secondary outcomes included participant perceptions of the checklist usefulness in identifying and managing dysrhythmias. We used generalized estimating equations (GEE) models, which accounted for clustering within groups, to evaluate the effects of the intervention. A total of 24 simulations were conducted; one of the 24 simulations was excluded due to an insufficient number of participants. In our GEE analysis, 81.21% (78.96%, 83.47%) of critical steps were completed with checklists available versus 68.06% (59.38%, 76.74%) without checklists (p = 0.004). Ninety-three percent of study participants reported that they would use the checklists during an unstable dysrhythmia of a child with underlying cardiac disease. Checklists were associated with improved adherence to lifesaving processes during simulated resuscitations for unstable pediatric dysrhythmias. These findings support the use of scenario specific checklists for the management of unstable dysrhythmias in simulations involving pediatric patients with underlying cardiac disease. Future studies should investigate whether checklists are as effective in actual pediatric in-hospital emergencies.

New Right Ventricular Dysfunction in Pediatric Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation.

The development of new right ventricular (RV) dysfunction after cannulation to venovenous (VV) extracorporeal membrane oxygenation (ECMO) and its association with worse outcomes is increasingly recognized in adult patients, however, no studies have evaluated this phenomenon in pediatric patients. We report results of a single-center retrospective cohort study at a large academic children's hospital. New RV systolic dysfunction was present in 48% (12/25) of pediatric patients on VV ECMO for acute respiratory distress syndrome (ARDS). There was no statistically significant difference in survival, duration of mechanical ventilation, or hospital length of stay between those with and without RV dysfunction. Over half (5/9, 56%) of survivors with RV dysfunction on ECMO had RV dilation or RV hypertrophy on post-ECMO echocardiograms, and in two patients the RV dysfunction persisted for months following decannulation. Cardiac catheterization and autopsy reports suggested that echocardiographic assessment of RV systolic function alone may not be sufficient to diagnose clinically relevant RV injury. This is the first study to report the prevalence of RV dysfunction on VV ECMO for pediatric ARDS. Future multicenter collaboration is needed to create a clinically relevant definition of pediatric "RV injury" and to further evaluate risk factors and outcomes of RV dysfunction.

Pediatric Acute Respiratory Distress Syndrome Severity and Health-Related Quality of Life Outcomes: Single-Center Retrospective Cohort, 2011-2017.

To determine factors associated with health-related quality of life (HRQL) decline among pediatric acute respiratory distress syndrome (PARDS) survivors. Retrospective cohort study. Academic children's hospital. Three hundred fifteen children 1 month to 18 years old with an unplanned PICU admission from December 2011 to February 2017 enrolled in the hospital's Outcomes Assessment Program. None. Pre-admission baseline and median 6-week post-discharge HRQL were assessed using the Pediatric Quality of Life Inventory or the Functional Status II-R. Patients meeting retrospectively applied Second Pediatric Acute Lung Injury Consensus Conference criteria for PARDS were identified, and PARDS severity was classified using binary (mild/moderate, severe) and trichotomous (mild, moderate, severe) categorization for noninvasive ventilation and invasive mechanical ventilation (IMV). PARDS occurred in 41 of 315 children (13.0%). Clinically important HRQL decline (≥ 4.5 points) occurred in 17 of 41 patients (41.5%) with PARDS and 64 of 274 without PARDS (23.4%). On multivariable generalized linear regression adjusted for age, baseline Pediatric Overall Performance Category, maximum nonrespiratory Pediatric Logistic Organ Dysfunction score, diagnosis, length of stay, and time to follow-up, PARDS was associated with HRQL decline (adjusted relative risk [aRR], 1.70; 95% CI, 1.03-2.77). Four-hour and maximum PARDS severity were the only factors associated with HRQL decline. HRQL decline occurred in five of 18 patients with mild PARDS at 4 hours, five of 13 with moderate PARDS (aRR 2.35 vs. no PARDS [95% CI, 1.01-5.50]), and seven of ten with severe PARDS (aRR 2.56 vs. no PARDS [95% CI, 1.45-4.53]). The area under the receiver operating characteristic curve for discrimination of HRQL decline for IMV patients was 0.79 (95% CI, 0.66-0.91) for binary and 0.80 (95% CI, 0.69-0.93) for trichotomous severity categorization. HRQL decline is common among children surviving PARDS, and risk of decline is associated with PARDS severity. HRQL decline from baseline may be an efficient and clinically meaningful endpoint to incorporate into PARDS clinical trials.

Changes in Inhaled Nitric Oxide Use Across ICUs After Implementation of a Standard Pathway.

Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator. It is expensive, frequently used, and not without risk. There is limited evidence supporting a standard approach to initiation and weaning. Our objective was to optimize the use of iNO in the cardiac ICU (CICU), PICU, and neonatal ICU (NICU) by establishing a standard approach to iNO utilization. A quality improvement study using a prospective cohort design with historical controls. Four hundred seven-bed free standing quaternary care academic children's hospital. All patients on iNO in the CICU, PICU, and NICU from January 1, 2017 to December 31, 2022. Unit-specific standard approaches to iNO initiation and weaning. Sixteen thousand eighty-seven patients were admitted to the CICU, PICU, and NICU with 9343 in the pre-iNO pathway era (January 1, 2017 to June 30, 2020) and 6744 in the postpathway era (July 1, 2020 to December 31, 2022). We found a decrease in the percentage of CICU patients initiated on iNO from 17.8% to 11.8% after implementation of the iNO utilization pathway. We did not observe a change in iNO utilization between the pre- and post-iNO pathway eras in either the PICU or NICU. Based on these data, we estimate 564 total days of iNO (-24%) were saved over 24 months in association with the standard pathway in the CICU, with associated cost savings. Implementation of a standard pathway for iNO use was associated with a statistically discernible reduction in total iNO usage in the CICU, but no change in iNO use in the NICU and PICU. These differential results likely occurred because of multiple contextual factors in each care setting.

The impact of specialized pediatric palliative care on advance care planning and healthcare utilization in children and young adults: a retrospective analysis of medical records of in-hospital deaths.

Pediatric palliative care supports children and young adults with life-limiting conditions and their families, seeking to minimize suffering and enhance quality of life. This study evaluates the impact of specialized palliative care (SPC) on advance care planning (ACP) and patterns of end-of-life care for patients who died in the hospital. This is a retrospective cohort study of medical records extracted from a clinical data warehouse, covering patients who died aged 0-24 in an academic tertiary children's hospital in South Korea. Participants were categorized into before (2011-2013; pre-period) and after (2017-2019; post-period) the introduction of an SPC service. Within the post-period, patients were further categorized into SPC recipients and non-recipients. We identified 274 and 205 patients in the pre-period and post-period, respectively. ACP was conducted more and earlier in the post-period than in the pre-period, and in patients who received palliative care than in those who did not. Patients who received SPC were likely to receive less mechanical ventilation or cardiopulmonary resuscitation and more opioids. A multivariable regression model showed that earlier ACP was associated with not being an infant, receiving SPC, and having a neurological or neuromuscular disease. SPC involvement was associated with more and earlier ACP and less intense end-of-life care for children and young adults who died in the hospital. Integrating palliative care into routine care can improve the quality of end-of-life care by reflecting patients' and their families' values and preferences.

A Review of Socioeconomic Disparities in Submucous Cleft Diagnosis and Outcomes.

Submucous cleft palate (SMCP) is a common congenital anomaly characterized by a diastasis of the levator veli palitini muscle. The subtlety of SMCP on physical examination can contribute to diagnostic delays. This study aims to analyze the factors contributing to delays in care and subsequent postoperative outcomes in patients with SMCP. All patients with surgical indications for SMCP who underwent palatoplasty at an urban academic children's hospital were included. Patient socioeconomic characteristics, medical history, and postoperative outcomes were collected. Patients were compared based on insurance type and government assistance utilization. Statistical analyses including independent t-test, Wilcoxon ranked sum test, χ2 analyses, Fisher's exact test, and stepwise logistic regression were performed. Among the 105 patients with SMCP, 69.5% (n=73) had public insurance and 30.5% (n=32) private. Patients with public insurance were diagnosed later (5.5±4.6 versus 2.6±2.4 years old; p<0.001) and underwent palatoplasty later (7.3±4.1 versus 4.4±3.4 years old; p<0.001) than those with private insurance. Patients receiving government assistance experienced higher rates of post-surgical persistent velopharyngeal insufficiency (74.5% versus 44.8%; p=0.006). The authors' results suggest a disparity in the recognition and treatment of surgical SMCP. Hence, financially vulnerable populations may experience an increased risk of inferior speech outcomes and subsequent therapies and procedures.

A prospective observational study of sleep patterns and work-related communications during home call for a pediatric surgery fellow

ObjectiveA pediatric surgery fellow is often regarded as a cornerstone of an academic children's hospital due to the need for their clinical services with overnight coverage being an important aspect of the care provided. There is little known about the objective sleep patterns and work-related communications of a pediatric surgery fellow during overnight home call. The aim of this study is to better understand the sleep patterns and interruptions of an on-call pediatric surgery fellow. DesignA prospective observational study of 60 call nights and 60 non-call nights of a pediatric surgery senior fellow was performed from September 2022 to February 2023. SettingAn academic Children's Hospital. ParticipantAn ACGME-accredited clinical pediatric surgery fellow. ResultsOn average, the pediatric surgery fellow spent 6.9 and 5.8 total hours in bed and asleep each night, respectively. The total sleep time was less for call nights compared to non-call nights (5.4 versus 6.3 h, p < 0.0001). The mean number of work-related communications per 12-hour night shift was four. The majority of communications were regarding new consults (63.8 %). The pediatric surgery fellow spent an average of 5.9 min per communication and approximately 23.8 min total during each 12-hour night shift. Approximately half of these communications occurred during sleep hours. ConclusionsThis study reveals overall sleep duration was below recommended levels. There were significant alterations in sleep patterns during call nights. Work-related communications further compounded sleep disturbances. Further research and interventions in this area are warranted.

Moving Biosurveillance Beyond Coded Data Using AI for Symptom Detection From Physician Notes: Retrospective Cohort Study.

Real-time surveillance of emerging infectious diseases necessitates a dynamically evolving, computable case definition, which frequently incorporates symptom-related criteria. For symptom detection, both population health monitoring platforms and research initiatives primarily depend on structured data extracted from electronic health records. This study sought to validate and test an artificial intelligence (AI)-based natural language processing (NLP) pipeline for detecting COVID-19 symptoms from physician notes in pediatric patients. We specifically study patients presenting to the emergency department (ED) who can be sentinel cases in an outbreak. Subjects in this retrospective cohort study are patients who are 21 years of age and younger, who presented to a pediatric ED at a large academic children's hospital between March 1, 2020, and May 31, 2022. The ED notes for all patients were processed with an NLP pipeline tuned to detect the mention of 11 COVID-19 symptoms based on Centers for Disease Control and Prevention (CDC) criteria. For a gold standard, 3 subject matter experts labeled 226 ED notes and had strong agreement (F1-score=0.986; positive predictive value [PPV]=0.972; and sensitivity=1.0). F1-score, PPV, and sensitivity were used to compare the performance of both NLP and the International Classification of Diseases, 10th Revision (ICD-10) coding to the gold standard chart review. As a formative use case, variations in symptom patterns were measured across SARS-CoV-2 variant eras. There were 85,678 ED encounters during the study period, including 4% (n=3420) with patients with COVID-19. NLP was more accurate at identifying encounters with patients that had any of the COVID-19 symptoms (F1-score=0.796) than ICD-10 codes (F1-score =0.451). NLP accuracy was higher for positive symptoms (sensitivity=0.930) than ICD-10 (sensitivity=0.300). However, ICD-10 accuracy was higher for negative symptoms (specificity=0.994) than NLP (specificity=0.917). Congestion or runny nose showed the highest accuracy difference (NLP: F1-score=0.828 and ICD-10: F1-score=0.042). For encounters with patients with COVID-19, prevalence estimates of each NLP symptom differed across variant eras. Patients with COVID-19 were more likely to have each NLP symptom detected than patients without this disease. Effect sizes (odds ratios) varied across pandemic eras. This study establishes the value of AI-based NLP as a highly effective tool for real-time COVID-19 symptom detection in pediatric patients, outperforming traditional ICD-10 methods. It also reveals the evolving nature of symptom prevalence across different virus variants, underscoring the need for dynamic, technology-driven approaches in infectious disease surveillance.