Academic Pediatric Hospital Research Articles

90 Perceived Barriers to the Provision of Adolescent Confidential Care in the Tertiary Care Setting

Abstract Background A cornerstone of quality adolescent health care is assuring confidential time for adolescent patients. Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Several national societies endorse the need for confidential care at all health-related encounters with adolescents. Many adolescents have infrequent contact with the medical system other than unscheduled urgent care in pediatric hospitals. Little is known regarding the effectiveness and feasibility of providing confidential care to adolescents in a tertiary pediatric hospital setting. Objectives We hypothesized that significant variation exists in the frequency and quality of confidential care delivery for adolescents. This study sought to characterize clinician comfort with confidentiality provision as well as identification of potential predicators and barriers to providing confidential care for adolescents in a tertiary, pediatric hospital setting. Design/Methods We undertook a cross-sectional survey among Emergency Department (ED), Hospitalist and Resident physicians at an urban, academic pediatric center. Data was collected using a standardized, self-administered electronic questionnaire. Survey participants responded to multiple-choice questions to characterize their comfort and self-identified barriers to providing confidential care to adolescents. Results Response rate was 91% (n=72/79; 26 ED, 14 Hospitalists, 32 Residents). A majority of respondents were female (69%), under the age of 50 (60%) and within their first 10 years of practice (51%). Forty-seven percent of respondents reported being somewhat/very doubtful that confidential care was being consistently provided to adolescents. Eighty-nine percent of respondents identified barriers to the quantity or quality of confidential care provided. Factors most commonly reported to influence physician decision to provide confidential care were diagnosis (75%), time of visit (45%), and patient age (25%). Among attending physicians 60% reported that they usually/always provide confidential care to adolescents, and 83% ensure that their trainees offer confidential care; whereas only 31% of trainees reported usually/always providing confidential care themselves (p=0.01). Limits of confidentiality were more likely to be explained to adolescent patients compared to their parents (83% vs. 33%; p<0.001). The most common reasons identified limiting the provision of confidential care were insufficient time (21%), perceived parental resistance (26%), lack of private space (26%) and the belief that it is not necessary for all adolescent encounters (34%). Forty percent of respondents reported discussing sensitive topics with adolescents in front of family members. Among both attending physicians and trainees, only 45% felt they had received adequate training on how best to deliver confidential care and similarly, 75% in both groups reported a desire for additional training. Conclusion Survey results suggest inadequate provision of confidential care in an academic pediatric hospital, with several potentially modifiable barriers. Confidentiality-specific education likely represents an important intervention to optimize physician comfort and improve the delivery of appropriate confidential care for adolescents.

The association between pre-tonsillectomy education and postoperative emergency department returns: A retrospective cohort pilot study

IntroductionTonsillectomy is the most common pediatric surgery in Canada. Post-tonsillectomy 30-day Emergency Department (ED) visit rates are higher than other pediatric day surgeries. To date, there have been no studies assessing whether additional preoperative education directed by Child Life Specialists impacts preventable ED visits. The primary aim of this study was to evaluate whether additional preoperative tonsillectomy education is feasible and is associated with fewer ED visits and admissions in the immediate postoperative period compared to standard care. The secondary aim of this study was to assess whether this education was associated with a lower ED visit rate for preventable causes. MethodsThis is a retrospective chart review conducted in an academic tertiary pediatric hospital. Patients undergoing tonsillectomy surgery (from 2014 to 2019) were divided into three groups: consultation with a Child Life Specialist plus educational Booklet plus traditional surgeon-led education (CLS), educational Booklet plus surgeon-led education (Booklet), and traditional surgeon-led education (Traditional). The feasibility of the CLS education was assessed and the 30-day ED visit and admission rates were compared between groups. Visits included patients who returned to ED post-tonsillectomy and were not admitted, whereas admission included those who returned to ED and were admitted. Results2081 patients undergoing tonsillectomy were included. 329 (15.8%) presented to the ED (within a median of 5 days), and 92 (4.4%) were admitted. ED visit/admission rates by group were: 14.7%/4.4% (CLS), 15.8%/4.1% (Booklet), and 16.2%/4.7% (Traditional) (p = 0.81/p = 0.84). The most common reason for return to ED was Hemorrhage (4.9%). Patients also returned to the ED for preventable reasons such as dehydration, pain, nausea/vomitting and fevers. ConclusionsAdditional preoperative tonsillectomy education is feasible but is not associated with fewer ED visits and admissions, or fewer ED visits for preventable causes. Further research is needed to identify the optimal intervention to address the high post-tonsillectomy ED visit rate.

The Impact of an Urban Scrapyard Fire on Respiratory-Related Pediatric Emergency Department Visits.

In Philadelphia, a scrapyard fire generated PM2.5 concentrations >1000 μg/m. We assessed whether this was associated with pediatric emergency department visits for respiratory diagnoses. Retrospective observational study using electronic health record data from a local, academic pediatric hospital. Compared to the two-week period before the fire, patients living directly north of the fire (downwind) had a significant difference in all asthma diagnoses (OR = 3.02, P = 0.03); asthma and upper respiratory infection (OR = 17.3, P = 0.01); overall admissions (OR = 3.04, P = 01); asthma admissions (OR = 4.45, P = .01); and asthma and upper respiratory infection admissions (OR = 15.0, P = 0.01). We did not observe any significant differences among visits or admissions from patients residing in other adjacent zip codes. A localized, transient increase in PM2.5 was associated with increased pediatric emergency department visits for asthma among patients living downwind of the fire.

Systems-focused simulation to prepare for COVID-19 intraoperative emergencies.

Although intraoperative emergencies are uncommon,1 we need to develop evidence-informed and contextualized guidance for intraoperative emergencies involving patients with COVID-19. At our academic pediatric hospital, we assembled a multi-disciplinary team to examine and adapt intraoperative emergency workflows to ensure safety for patients with suspected COVID-19 infection, and limit exposure for healthcare providers, with a focus on system improvement (rather than individual performance).

Infection Prevention Response to a Pediatric Patient with NDM-producing Enterobacter Colonization Without International Travel

<h3>Background</h3> Carbapenem-resistant Enterobacteriaceae (CRE) infections are associated with high mortality worldwide, primarily due to delayed administration and limited availability of effective antibiotics. Some CRE produce carbapenemases, which confer increased resistance that can be transmitted horizontally to other Gram-negative bacteria. Although some carbapenemases, including Klebsiella pneumoniae carbapenemase, are now considered endemic in the United States, New Delhi metallo-β-lactamases (NDM) remain unusual in the U.S. and are typically associated with receipt of healthcare abroad. Here, we characterize the epidemiological investigation and infection prevention interventions implemented after an NDM-producing CRE was identified at a 490-bed academic pediatric hospital in Texas in a lymphoma patient admitted to the intensive care unit with no history of international travel. <h3>Methods</h3> Epidemiological investigation included a six-month retrospective review of CRE cases, point-prevalence survey for carriage of carbapenemase-producing isolates among inpatients admitted to the same unit as the index patient, and three-month prospective surveillance for carbapenem resistance. Infection prevention interventions were implemented to prevent hospital-based transmission of CRE. <h3>Results</h3> Six-month retrospective surveillance identified 11 CRE, but no high-level resistance or carbapenemase production. Carbapenemases were not detected in point-prevalence testing of 17 patients concurrently hospitalized in the same unit or in four additional CRE isolates identified during prospective surveillance. Infection prevention interventions included staff education; contact precautions and hand hygiene audits; additional cleaning measures in index patient rooms, including daily floor disinfection and ultraviolet light terminal disinfection; and continuation of contact precautions for the index patient during any subsequent admissions and outpatient visits. <h3>Conclusions</h3> Our investigation did not detect evidence of hospital-based transmission of NDM-CRE, suggesting the index isolate may have been acquired in the community and highlighting the potential for local transmission of NDM-producing isolates even in the absence of previously characterized risk factors. Ongoing surveillance and infection prevention strategies are necessary to detect CRE and prevent its transmission.

The Pediatric-Specific American Society of Anesthesiologists Physical Status Score: A Multicenter Study.

When applied to the pediatric population, the American Society of Anesthesiologists physical status (ASA-PS) classification has exhibited poor reliability due to its subjective and adult-focused definitions. This study was done to measure interrater agreement of a pediatric-adapted ASA-PS classification and to solicit multicenter perspectives to optimize the pediatric ASA-PS classification. A prospective, mixed-methods study of 197 pediatric anesthesiologists from 13 academic pediatric hospitals in the United States, Europe, and Australia surveyed in May and July 2019. Participants assigned ASA-PS scores (I to V) for 15 pediatric cases with a heterogeneous mix of acute and chronic health conditions undergoing a variety of surgical and related procedures. Pediatric-adapted definitions of ASA-PS were provided. The intraclass correlation coefficient (ICC) was used to assess interrater reliability of ASA-PS scores. The ICC was estimated using 2-way mixed-effects modeling, accounting for multiple raters assigning scores for the same set of cases. Qualitative feedback on the pediatric-adapted ASA-PS classification was analyzed with line-by-line coding. The survey response rate was 83.8% (165 of 197). The ICC agreement among participants on ASA-PS scoring across all 15 clinical cases was 0.58 (95% confidence interval [CI], 0.42-0.77). ICC did not vary significantly by years of anesthesiology practice. ICC varied across hospitals (range: 0.34; 95% CI, 0.12-0.63 to 0.79; 95% CI, 0.66-0.91). The highest level of agreement occurred with cases most often scored as ASA-PS I, IV, and V; the lowest agreement occurred with cases most often scored ASA-PS II and III. Clarification of how well a chronic condition was controlled and presence of an acute illness were 2 common themes suggested to optimize the validity of the pediatric-adapted ASA-PS definitions. The pediatric-adapted ASA-PS classification had moderate interrater reliability among pediatric anesthesiologists. The lower reliability of scoring for ASA-PS II and III cases, in particular, supports the need for further ASA-PS definition refinement for pediatric populations.

Lessons Learned Over A Twenty Year Experience in the Utilization of Advanced Practice Providers in a Large Academic Pediatric Critical Care Medical Setting

Purpose: In 1999 to 2000, a large tertiary academic pediatric hospital expanded clinical coverage of medically complex and critically ill patients from 24 to 36 beds. Without additional resident, fellow, or faculty physician coverage allocated to the unit, the hospital incentivized 6 pediatric intensive care unit Registered Nurses to complete their pediatric nurse practitioner training. They were offered a two-year commitment and employment as Advanced Practice Provider (APP) faculty for the Department of Pediatrics to form a new service line. During the first …

Pediatric Cardiopulmonary Resuscitation Tasks and Hands-Off Time: A Descriptive Analysis Using Video Review.

To characterize tasks performed during cardiopulmonary resuscitation in association with hands-off time, using video recordings of resuscitation events. Single-center, prospective, observational trial. Twenty-six bed cardiac ICU in a quaternary care free standing pediatric academic hospital. Patients admitted to the cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video. None. Videos of 17 cardiopulmonary resuscitation episodes comprising 264.5 minutes of cardiopulmonary resuscitation were reviewed: 11 classic cardiopulmonary resuscitation (87.5 min) and six extracorporeal cardiopulmonary resuscitations (177 min). A total of 209 tasks occurred in 178 discrete time periods including compressor change (36%), rhythm/pulse check (18%), surgical pause (18%), extracorporeal membrane oxygenation preparation/draping (9%), repositioning (7.5%), defibrillation (6%), backboard placement (3%), bagging (<1%), pacing (<1%), intubation (<1%). In 31 time periods, 62 tasks were clustered with 18 (58%) as compressor changes and pulse/rhythm check. In the 178 discrete time periods, 135 occurred with a pause in compressions for greater than or equal to 1 second; 43 tasks occurred without pause. After accounting for repeated measures from individual patients, providers were less likely to perform rhythm or pulse checks (p < 0.0001) or change compressors regularly (p = 0.02) during extracorporeal cardiopulmonary resuscitation as compared to classic cardiopulmonary resuscitation. The frequency of tasks occurring during cardiopulmonary resuscitation interruptions in the classic cardiopulmonary resuscitation group was constant over the resuscitation but variable in extracorporeal cardiopulmonary resuscitation, peaking during activities required for cannulation. On video review of cardiopulmonary resuscitation, we found that resuscitation guidelines were not strictly followed in either cardiopulmonary resuscitation or extracorporeal cardiopulmonary resuscitation patients, but adherence was worse in extracorporeal cardiopulmonary resuscitation. Clustering of resuscitation tasks occurred 23% of the time during chest compression pauses suggesting attempts at minimizing cardiopulmonary resuscitation interruptions. The frequency of cardiopulmonary resuscitation interruptions task events was relatively constant during classic cardiopulmonary resuscitation but variable in extracorporeal cardiopulmonary resuscitation. Characterization of resuscitation tasks by video review may inform better cardiopulmonary resuscitation orchestration and efficiency.

Learning in Pediatric Emergency Situations: A Qualitative Study of Residents' Perspectives.

To explore resident learning in the context of emergency situations. The guiding research questions were: How do residents learn in emergency situations? What factors facilitate or hinder their learning? A qualitative approach was used in order to understand the different perspectives of participants and explore the context of emergency situations. Aware of the complex sociocultural interactions in emergency situations, we used the methodology of constructivist grounded theory. A medium-sized pediatric academic hospital in San Antonio, TX. Twenty pediatric residents participated in semi-structured interviews. None. We used an iterative process of data collection and analysis. The process continued until thematic saturation was reached. The data were coded and analyzed using constant comparison. Codes were clustered into themes informed by the theory of situated learning. Several methods were used to ensure trustworthiness of results. Three main themes were identified. First, resident participation in emergency situations takes different forms. Residents participate mostly in helping roles. Watching is an under-recognized form of participation yet offered unique experiences. Managing roles are rarely afforded to residents. Second, resident participation is informed by the context of the emergency situation. Based on contextual clues (e.g., safety, needs), residents infer potential risks and values from their participation, which guides their participatory role. Residents may shift their form of participation, based on changes in the context. Supervisors play a significant role in guiding resident participation. Third, engagement, a state of cognitive and emotional focus, is critical in learning. The context of the emergency situation plays a role in the level of resident engagement. Supervisors may also foster resident engagement. Resident participation in emergency situations is complex and informed by the context. Learning in emergency situations is influenced by residents' level of mental engagement. Supervisors may positively guide resident participation, foster engagement, and enable them to reach their learning goals in emergency situations.

Imaging features of pathologically proven pediatric splenic masses

Splenic masses present a diagnostic challenge to radiologists and clinicians alike, with a relative paucity of data correlating radiologic findings to pathological diagnosis in the pediatric population. To illustrate splenic mass imaging findings and approximate lesion prevalence, we retrospectively reviewed all splenectomies and splenic biopsies for splenic masses at a single academic pediatric hospital over a 10-year period in patients 18years and younger. A total of 31 splenic masses were analyzed. Lesion prevalence, pathology and imaging features associated with sampled splenic masses are described. The lesions encountered include benign splenic cysts (9), vascular anomalies (7), hamartoma (3), leukemia/lymphoma (3), granulomata (3) and metastasis (2). We also identified single cases of angiosarcoma, splenic cord capillary hemangioma, congestive hemorrhage, and benign smooth muscle neoplasm.

1249-P: Type 2 Diabetes in Prepubertal Children under 10 Years Old

Only a few cases of type 2 diabetes (T2D) have been reported in children younger than 10 years of age. Given the aggressiveness of youth-onset T2D and the accelerated development of comorbidities and complications, recognition of this unique subgroup and its characteristics is imperative. We aimed to determine the prevalence and characteristics of children with T2D diagnosed &amp;lt;10 years old (y/o) at a large academic pediatric hospital in the Southwestern U.S. We conducted a retrospective review of electronic medical records of 1,138 children and adolescents up to 21 years of age who were given a diagnosis of T2D in our clinic. We compared the demographic and biochemical characteristics at the time of diabetes diagnosis between children diagnosed &amp;lt;10 y/o vs. ≥10 y/o, and by puberty status within the &amp;lt;10 y/o group. In our overall T2D population, 67.3% were females, 9.9% non-Hispanic White (NHW), 59% Hispanic (Hisp), 26.8% African-American (AA). The mean age at diagnosis was 13.8± 2.6 (±SD) y/o (range 3.0-21.7). The children diagnosed with T2D &amp;lt;10 y/o constituted 5.6%, n=64 of our total T2D population; mean age 8.8± 1.0 y/o (range 4.1-9.9). 52.2% were prepubertal (Tanner Stage [TS]-I). 81.2% had islet autoantibodies test available (including GAD, ICA-512 and IAA) and all had negative results. Children with T2D diagnosed &amp;lt;10 y/o were more likely to be female (79.7%) than youth diagnosed ≥10 y/o (61.4%, p=0.003). We observed no racial/ethnic distribution differences between the two groups (p=0.58). Within the group diagnosed &amp;lt;10 y/o, children who were prepubertal, compared with those at ≥TS-II, were more likely to be male (33.3% vs. 0%, p=0.035), had a higher BMI-Z score (2.71 vs. 2.47, p=0.036), and tended to have a different racial/ethnic distribution (83.3% Hisp and 16.7% AA vs. 45.5% and 54.6%, respectively, p=0.057). In conclusion, less than 10% of youth with T2D are diagnosed under age 10 years; those in this group who are prepubertal (&amp;gt;50%) are distinctly atypical and have other unique characteristics that warrant further study. Disclosure M. Astudillo: None. A.K. Refaey: None. M. Tosur: None. A.F. Siller: None. S. Mckay: None. A. Balasubramanyam: None. F. Bacha: Research Support; Self; AstraZeneca, Takeda Development Center Americas, Inc. M.J. Redondo: None.

Efficient Postoperative Disposition Selection in Pediatric Otolaryngology Patients: A Novel Approach.

Pediatric patients undergoing surgery on the aerodigestive tract require a wide range of postoperative airway support that may be difficult predict in the preoperative period. Inaccurate prediction of postoperative resource needs leads to care inefficiencies in the form of unanticipated intensive care unit (ICU) admissions, ICU bed request cancellations, and overutilization of ICU resources. At our hospital, inefficient utilization of pediatric intensive care unit (PICU) resources was negatively impacting safety, access, throughput, and finances. We hypothesized that actionable key drivers of inefficient ICU utilization at our hospital were operative scheduling errors and the lack of predictability of intermediate-risk patients and that improvement methodology could be used in iterative cycles to enhance efficiency of care. Through testing this hypothesis, we aimed to provide a framework for similar efforts at other hospitals. Quality improvement initiative. Plan, Do, Study, Act methodology (PDSA) was utilized to implement two cycles of change aimed at improving level-of-care efficiency at an academic pediatric hospital. In PDSA cycle 1, we aimed to address scheduling errors with surgical order placement restriction, creation of a standardized list of surgeries requiring PICU admission, and implementation of a hard stop for postoperative location in the electronic medical record surgical order. In the PDSA cycle 2, a new model of care, called the Grey Zone model, was designed and implemented where patients at intermediate risk of airway compromise were observed for 2-5 hours in the post-anesthesia care unit. After this observation period, patients were then transferred to the level of care dictated by their current status. Measures assessed in PDSA cycle 1 were unanticipated ICU admissions and ICU bed request cancellations. In addition to continued analysis of these measures, PDSA cycle 2 measures were ICU beds avoided, safety events, and secondary transfers from extended observation to ICU. In PDSA cycle 1, no significant decrease in unanticipated ICU admissions was observed; however, there was an increase in average monthly ICU bed cancellations from 36.1% to 45.6%. In PDSA cycle 2, average monthly unanticipated ICU admissions and cancelled ICU bed requests decreased from 1.3% to 0.42% and 45.6% to 33.8%, respectively. In patients observed in the Grey Zone, 229/245 (93.5%) were transferred to extended observation, avoiding admission to the ICU. Financial analysis demonstrated a charge differential to payers of $1.1 million over the study period with a charge differential opportunity to the hospital of $51,720 for each additional hospital transfer accepted due to increased PICU bed availability. Implementation of the Grey Zone model of care improved efficiency of ICU resource utilization through reducing unanticipated ICU admissions and ICU bed cancellations while simultaneously avoiding overutilization of ICU resources for intermediate-risk patients. This was achieved without compromising safety of patient care, and was financially sound in both fee-for-service and value-based reimbursement models. While such a model may not be applicable in all healthcare settings, it may improve efficiency at other pediatric hospitals with high surgical volume and acuity. N/A Laryngoscope, 131:S1-S10, 2021.

Implementing daily chlorhexidine gluconate treatment for the prevention of healthcare-associated infections in non-intensive care settings: A multiple case analysis.

IntroductionDaily bathing with chlorhexidine gluconate (CHG) in hospitalized patients reduces healthcare-associated bloodstream infections and colonization by multidrug-resistant organisms. Achieving compliance with bathing protocols is challenging. This non-intensive care unit multicenter project evaluated the impact of organizational context on implementation of CHG and assessed compliance with and healthcare workers’ perceptions of the intervention.Materials and methodsThis was a multiple case study based on the SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety. The four sites included an adult cardiovascular unit in a community hospital, a medical-surgical unit in an academic teaching pediatric hospital, an adult medical-surgical acute care unit and an adult neuroscience acute care unit in another academic teaching hospital. Complementary data collection methods included focus groups and interviews with healthcare workers (HCWs) and leaders, and direct observations of the CHG treatment process and skin swabs.ResultsWe collected 389 bathing observations and 110 skin swabs, conducted four focus groups with frontline workers and interviewed leaders. We found variation across cases in CHG compliance, skin swab data and implementation practices. Mean compliance with the bathing process ranged from 64% to 83%. Low detectable CHG on the skin was related to immediate rinsing of CHG from the skin. Variation in the implementation of CHG treatments was related to differences in organizational education and training practices, feedback and monitoring practices, patient education or information about CHG treatments, patient preferences and general unit patient population differences.ConclusionOrganizations planning to implement CHG treatments in non-ICU settings should ensure organizational readiness and buy-in and consider delivering systematic and ongoing training. Clear and systematic implementation policies across patients and units may help reduce potential confusion about treatment practices and variation across HCWs. Patient populations and unit factors need to be carefully considered and procedures developed to manage unique challenges.

Too old for a paediatric emergency department? It's complex.

In Ireland, the paediatric emergency department (PED) is tasked with acute healthcare provision to children and adolescents under 16years of age. The population > 15years attending the PED remains undescribed. The objective of the study is to describe the presentations of patients > 15years to the PED of a national tertiary academic paediatric hospital. A retrospective review of electronic records identifying all patients (> 15years) who presented from January 2014 to December 2015. Patient demographics, presenting complaint, diagnosis, treatment and disposition were recorded. A total of 71,082 patients attended during the study period; of whom, 426 (0.6%) patients were aged 16 to 61years. Over half were identified as having clearly defined chronic complex conditions. Three hundred and forty-five (89%) patients were known to the hospital paediatric services and under the care of specialist with 131 (34%) patients admitted locally, all of whom had chronic complex conditions (CCC). There was a total of 44 (11%) patients who presented to the PED with de novo issues and had a variety of acute presenting complaints with minor injuries, syncope and chest pain being most common. This is the first Irish study demonstrating a significant population (> 15years) with medical complexity that requires a suite of services in a paediatric hospital which is accessed in an unscheduled manner through an emergency department. We recommend further research to describe paediatric CCC attending Irish emergency and hospital services.

Comparison of antibiotic and acyclovir usage before and after the implementation of an on-site FilmArray meningitis/encephalitis panel in an academic tertiary pediatric hospital: a retrospective observational study

BackgroundPrompt initiation of empiric therapy is common practice in case of suspected meningitis or encephalitis. However, in children the most common pathogens are viruses that usually do not require and are not covered by the applied anti-infective treatment. Novel multiplex PCR (mPCR) panels provide rapid on-site diagnostic testing for a variety of pathogens. This study compared empiric antibiotic and acyclovir usage before and after the introduction of an on-site FilmArray Meningitis/Encephalitis Panel (FA ME Panel).MethodsWe retrospectively compared data for empiric antibiotic and acyclovir usage between pediatric patients with suspected central nervous system (CNS) infection receiving mPCR testing and a matched historical control group. Patients were matched by age and suspected CNS infection. We included all patients for whom empiric antibiotics and/or acyclovir were prescribed.ResultsEach study group consisted of 46 patients with 29 (63.0%) infants and 17 (37.0%) older children. A viral pathogen was diagnosed in 5/46 (10.9%) patients in the control group (all enteroviruses) and in 14/46 (30.4%) patients in the mPCR group (enterovirus n = 9; human herpesvirus 6 (HHV-6) n = 5), (p = 0.038)). Length of Therapy (LoT) and Days of Therapy (DoT) for antibiotics were significantly lower for infants (4.0 vs. 3.0, p = 0.038 and 8.0 vs. 6.0, p = 0.015, respectively). Acyclovir therapy was significantly shorter for both, infants and older children (3.0 vs. 1.0 day, p < 0.001 for both age groups).ConclusionThe findings of our study suggest that the introduction of a FA ME Panel into clinical routine procedures is associated with a significantly reduced LoT and DoT of empiric anti-infective treatment in children with suspected meningoencephalitis. The largest effect was observed in infants.

Validation of a Simple Tool for Electronic Documentation of Behavioral Responses to Anesthesia Induction.

Anxiety and distress behaviors during anesthesia induction are associated with negative postoperative outcomes for pediatric patients. Documenting behavioral responses to induction is useful to evaluate induction quality at hospitals and to optimize future anesthetics for returning patients, but we lack a simple tool for clinical documentation. The Induction Compliance Checklist is a tool for grading induction behaviors that is well validated for research purposes, but it is not practical for routine documentation in busy clinical practice settings. The Child Induction Behavioral Assessment tool was developed to provide a simple and easy to use electronic tool for clinical documentation of induction behaviors. The aim of this study was to test the Child Induction Behavioral Assessment tool's concurrent validity with the Induction Compliance Checklist and the interrater reliability. This prospective, observational study included 384 pediatric patients undergoing anesthesia inhalation induction. Concurrent validity with the Induction Compliance Checklist and interrater reliability of the Child Induction Behavioral Assessment were evaluated. Two researchers alternated scoring the Induction Compliance Checklist. The 2 researchers independently scored the Child Induction Behavioral Assessment. The anesthesia clinician caring for the patient also independently scored the Child Induction Behavioral Assessment by completing their routine documentation in the patient's medical record. Two age groups were evaluated (ages 1-3 and 4-12 years old). Clinicians' and researchers' Child Induction Behavioral Assessment scores demonstrated a strong correlation with the Induction Compliance Checklist (P < .0001). There was an excellent agreement between the 2 researchers' Child Induction Behavioral Assessment scores for the younger and older age groups, respectively (Kappa [95% CI] = 0.97 (0.94-0.99); K = 0.94 (0.89-0.99)]. The agreement between the researchers and the 117 clinicians who documented Child Induction Behavioral Assessment assessments in the medical record was good overall (intraclass correlation coefficient = 0.70), with fair agreement with the 1- to 3-year-old patients (intraclass correlation coefficient = 0.56) and good agreement for the 4- to 12-year-old patients (intraclass correlation coefficient = 0.74). The Child Induction Behavioral Assessment scale is a simple and practical electronic tool used to document pediatric behavioral responses to anesthesia inductions. This study provides evidence of the tool's validity and reliability for inhalation inductions. Future research is needed at other hospitals to confirm validity.

Defining Risk of Postoperative Obstructive Sleep Apnea in Patients With 22q11.2DS Undergoing Pharyngeal Flap Surgery for Velopharyngeal Dysfunction Using Polysomnographic Evaluation

To determine pre- and postoperative prevalence of obstructive sleep apnea (OSA) in patients with 22q11.2 deletion syndrome (DS) undergoing wide posterior pharyngeal flap (PPF) surgery for velopharyngeal dysfunction (VPD). Retrospective study using pre- and postoperative polysomnography (PSG) to determine prevalence of OSA. Medical records were reviewed for patients' medical comorbidities. Parents were surveyed about snoring. Academic tertiary care pediatric hospital. Forty patients with laboratory confirmed 22q11.2DS followed over a 6-year period. Pre- and postoperative PSG, speech evaluation, and parent surveys. Severity and prevalence of OSA, defined by obstructive apnea hypopnea index (OAHI), before and after PPF surgery to determine whether PPF is associated with increased risk of OSA. Mean OAHI did not change significantly after PPF surgery (1.1/h vs 2.1/h, P = .330). Prevalence of clinically significant OSA (OAHI ≥ 5) was identical pre- and postoperatively (2 of 40), with both cases having severe-range OSA requiring positive airway pressure therapy. All other patients had mild-range OSA. Nasal resonance was graded as severe preoperatively in 85% of patients. None were graded as severe postoperatively. No single patient factor or parent-reported concern predicted risk of OSA (OAHI ≥ 1.5). Patients with 22q11.2DS are medically complex and are at increased risk of OSA at baseline. Wide PPF surgery for severe VPD does not significantly increase risk of OSA. Careful perioperative planning is essential to optimize both speech and sleep outcomes.

Indoor exposure to airborne bacteria and fungi in sensitive wards of an academic pediatric hospital

Airborne bacteria and fungi in hospital environments are of great concern due to their potential role as a source of nosocomial infections. The aim of this study was to evaluate concentration and diversity of airborne bacteria and fungi in relation to particle mass concentration in sensitive wards of a pediatric hospital. The study was performed in the cardiac care unit (CCU), the neonatal intensive care unit (NICU), the cancer blood ward (BW), the ENT (ear, nose, throat) operation room (OT1) and the eye operation room (OT2). The air samples were collected by impaction using the single-stage Andersen sampler. The flow rate and sampling time of the pump were adjusted to 28.3 l/min for 5 min. The mean concentration of indoor airborne fungi and bacteria ranged from 0–63 to 19–356 CFU/m3, respectively. OT2 and CCU wards were the most contaminated wards for airborne bacteria and fungi, respectively (243 ± 77 vs. 30 ± 7 CFU/m3). The airborne Gram-positive cocci (Staphylococcus and Micrococcus) were the most detected bacterial genera (75%) in all indoor air samples, and the most prevalent genera in indoor environment were Cladosporium spp. (19%) followed by Penicillium spp. (16%), Aspergillus spp. (16%) and Paecilomyces spp. (10%). Results showed that the outdoor airborne bacteria and PM concentration at different sizes were significantly higher than indoors, suggesting that the indoor airborne particle may have originated from the outdoor air. There were significant positive relationships between indoor airborne fungi concentrations with indoor PM2.5 and PM10.

Association of Health Record Visualizations With Physicians’ Cognitive Load When Prioritizing Hospitalized Patients

Current electronic health records (EHRs) contribute to increased physician cognitive workload when completing clinical tasks. To assess the association of different design features of an EHR-based information visualization tool with the cognitive load of physicians during the clinical prioritization process. This cross-sectional study included a convenience sample of 29 attending physicians at Seattle Children's Hospital, a large tertiary academic pediatric hospital. Data collection took place from August 2017 through October 2017, and analysis occurred from August to October 2018. Physician participants used 3 prototypes with novel visualizations of simulated EHR data that highlighted 1 of 3 key patient characteristics, as follows: (1) acuity, (2) clinical problem list, and (3) clinical change. Cognitive workload was measured using the NASA Task Load Index (TLX) scale (range, 1-100, with lower scores indicating lower cognitive workload). Cognitive workload was assessed for the 2 following clinical prioritization tasks: (1) finding information for a specific patient and (2) comparing results among patients for each prototype. Participants ranked 5 hypothetical patients from having the highest to the lowest priority in each design. A total of 29 physician participants (15 [52%] men; 14 [48%] women; mean [range] age, 43 [35-58] years; mean [range] time in practice, 11 [3-30] years) completed the study. For task 1, the prototype highlighting clinical change was associated with lower median (interquartile range) NASA TLX scores compared with the prototype highlighting acuity (30.3 [15.2-41.6] vs 48.5 [18.7-59.3]; P = .02). For task 2, the prototype highlighting clinical change was associated with lower median (interquartile range) NASA TLX scores compared with the prototype highlighting the clinical problem list (29.1 [16.3-50.8] vs 43.5 [26.6-55.9]; P = .02). The prototype highlighting clinical change had the lowest TLX score in 17 of 29 rankings (59%) for task 1 (χ24 = 24.4; P < .001) and 18 of 29 rankings (62%) for task 2 (χ24 = 17.2; P = .002). In this study, well-designed EHR-based information visualizations that highlighted and featured clinically meaningful information patterns significantly reduced physician cognitive workload when prioritizing patient needs.

Opioid-Sparing Multimodal Analgesia After Selective Dorsal Rhizotomy.

Multimodal analgesia (MMA) may reduce opioid use among children who are hospitalized, and may contribute toward enhanced recovery after selective dorsal rhizotomy (SDR) for patients with spasticity in pediatric cerebral palsy. In this retrospective cohort study, we assess an MMA protocol consisting of scheduled nonsteroidal antiinflammatory drug doses (ketorolac or ibuprofen), alternating with scheduled acetaminophen and diazepam doses, with as-needed opioids. It was hypothesized that protocol use would be associated with reductions in opioid requirements and other clinical improvements. Data were obtained for 52 patients undergoing SDR at an academic tertiary care pediatric hospital (2012-2017, with the protocol implemented in 2014). Using a retrospective cohort design, we compared outcomes between protocol and nonprotocol patients, employing both univariate t test and Wilcoxon rank test comparisons as well as multivariable regression methods. The primary outcome was total as-needed opioid requirements over postoperative days (PODs) 0 to 2, measured in oral morphine milligram equivalents per kilogram. Additional outcomes included antiemetic medication doses, discharge opioid prescriptions, total direct cost, and length of stay. Twelve patients received the MMA protocol, and 40 patients did not. POD-0 MMA initiation was independently associated with a reduction of 0.14 morphine milligram equivalents per kilogram in mean opioid requirements over PODs 0 to 2 in the multiple regression analysis (95% confidence interval 0.01 to 0.28; P = .04). No statistically significant differences were demonstrated in doses of antiemetic medications, discharge opioid prescriptions, total direct cost, and length of stay. This MMA protocol may help reduce opioid use after SDR. Improving protocol implementation in a prospective, multisite study will help elucidate further MMA effects on pain, costs, and recovery.