Care Children's Hospital Research Articles

Mandibulotomy Technique and Permanent Molar Injury After Mandibular Distraction Osteogenesis in Infants.

The risk that mandibular distraction osteogenesis (MDO) poses to the developing mandibular dentition is well-known; however, less is understood about how the choice of instrumentation used for mandibular osteotomy might affect the development of permanent molars. Retrospective chart review examining infants with micrognathia who underwent MDO from 2010 to 2018 at a single tertiary care children's hospital using external, multivector devices. The first and second permanent mandibular molars were radiographically examined years after surgery to determine whether osteotomy cutting techniques affect the risk of injury to the permanent dentition. Thirty-seven infants and children underwent MDO from 2010 to 2018. Follow-up dental radiographs were available for 17 patients; 6 patients were excluded based on the use of preoperative computed tomography, utilization of virtual surgical planning technology, use of buried internal distractors, or older age at the time of distraction surgery. This yielded a total of 11 patients who underwent MDO with external hardware without virtual surgical planning representing 22 osteotomies. Sixteen osteotomies were performed using a side-cutting burr and 6 with a piezoelectric saw. The median age at distraction surgery was 3 weeks. The rate of an abnormal permanent first or second mandibular molar finding per osteotomy was 88% (14/16) in the side-cutting group versus 17% (1/6) with the piezoelectric technique (P = 0.004). Mandibular distraction osteogenesis risks injury to the mandibular molars; however, this study suggests a significant risk reduction in molar injury if the piezoelectric device is utilized.

Use of temporary tracheostomy occlusion to reduce the risk of sternal wound infection after sternotomy in congenital cardiac surgery.

To describe a method of reducing the risk of sternal wound infection after sternotomy in children with a pre-existing tracheostomy. To report our outcomes using this method from 1 January, 2013 to 31 August, 2023. We describe a method for temporarily occluding the tracheal stoma with a removable implant with the primary goal of reducing the risk of sternotomy wound infection by preventing soilage due to tracheostomal secretions. We then performed a retrospective review of all children who underwent temporary tracheostomal occlusion between 1 January, 2013 and 31 August, 2023 at our quaternary care children's hospital. Clinical variables were extracted from the hospital medical records. The rates of antibiotic use and minor and major complications during the period when the stoma plug was in place were recorded. Totally, 19 patients underwent tracheal stoma plugging prior to sternotomy and were included in our analysis. There were two cases of sternal wound infection; one case occurred while the stoma plug was in place, and one developed four days following plug removal. There was one minor complication, with one patient requiring stoma revision via serial dilation at bedside at the time of recannulation. There were no deaths. Temporary occlusion of the tracheal stoma with an impermeable plug is a viable option for reducing the risk of sternal wound infection in children with a pre-existing tracheostomy who are undergoing sternotomy.

Sociodemographic Factors are Associated with Care Delivery and Outcomes in Pediatric Severe Sepsis.

Sepsis is a leading cause of morbidity and mortality in the United States and disparate outcomes exist between racial/ethnic groups despite improvements in sepsis management. These observed differences are often related to social determinants of health (SDoH). Little is known about the role of SDoH on outcomes in pediatric sepsis. This study examined the differences in care delivery and outcomes in children with severe sepsis based on race/ethnicity and neighborhood context (as measured by the social vulnerability index). This retrospective, cross-sectional study was completed in a quaternary care children's hospital. Patients 18 years old or younger who were admitted between May 1, 2018, and February 28, 2022, met the improving pediatric sepsis outcomes (IPSO) collaborative definition for severe sepsis. Composite measures of social vulnerability, care delivery, and clinical outcomes were stratified by race/ethnicity. The primary outcome of interest was admission to the PICU. Secondary outcomes were sepsis recognition and early goal-directed therapy (EGDT). A total of 967 children met the criteria for IPSO-defined severe sepsis, of whom 53.4% were White/non-Hispanic. Nearly half of the cohort (48.7%) required PICU admission. There was no difference in illness severity at PICU admission by race (1.01 vs. 1.1, p = 0.18). Non-White race/Hispanic ethnicity was independently associated with PICU admission (odds ratio [OR] 1.35 [1.01-1.8], p = 0.04). Although social vulnerability was not independently associated with PICU admission (OR 0.95 [0.59-1.53], p = 0.83), non-White children were significantly more likely to reside in vulnerable neighborhoods (0.66 vs. 0.38, p < 0.001). Non-White race was associated with lower sepsis recognition (87.8% vs. 93.6%, p = 0.002) and less EGDT compliance (35.7% vs. 42.8%, p = 0.024). Non-White race/ethnicity was independently associated with PICU admission. Differences in care delivery were also identified. Prospective studies are needed to further investigate these findings.

Experience of an Italian Pediatric Third Level Emergency Department during the 2022-2023 Bronchiolitis Epidemic: A Focus on Discharged Patients and Revisits.

The aim of this study was to describe the 2022-2023 bronchiolitis epidemic season (the second after COVID-19 pandemic and the first without social restriction), focusing on patients discharged home from a pediatric emergency department (PED) and on those revisited within 72 h. We performed a retrospective observational study in an Italian tertiary care children's hospital, reviewing PED accesses from 1 October 2022 to 31 March 2023. The number of hospitalizations for bronchiolitis was extracted from hospital discharge forms. A total of 512 patients diagnosed with bronchiolitis were admitted to PED (2.8% of total admissions). Accesses increased sharply from November to January, with a peak in December, in both admissions and hospitalizations. More than half of the patients (55.5%) were safely discharged home, while 38 (13.4%) came back to PED for a revisit. Overall PED accesses and hospitalizations for bronchiolitis increased since the previous epidemic season, and particularly compared to the pandemic and pre-pandemic eras. Empowering the collaboration between all healthcare provisioners is fundamental to suitable management of patients. Monitoring the epidemiology and seasonality of bronchiolitis is a starting point for an effective internal organization of pediatric departments and to further evaluate its socio-economic burden.

Patient-Centered Outcomes in Bronchiolitis.

We examined the impact of hospitalization for bronchiolitis on patient-centered outcomes across patients with varying levels of support. The participants included primary caregivers of children aged 0 to 24 months hospitalized for bronchiolitis at an 150-bed tertiary care children's hospital. Data were collected using a 30-item questionnaire examining quality of life impact, adapted from the previously validated survey, the Impact of Bronchiolitis Hospitalization Questionnaire.1 The survey contained questions asking to what extent the hospitalization interfered with different aspects of care. After all surveys were collected, the patients were split into groups categorized by level of support and defined as no support, low support (low-flow nasal cannula only or nasogastric [NG] only), moderate support (high-flow nasal cannula without NG), high support (high-flow nasal cannula with NG support), and positive pressure (with or without NG support). Descriptive statistics were used to examine the distribution of mean impact scores across these groups. A total of 92 caregivers and their children were included. The mean impact score for variables of difficult to hold, difficult to bond, and breastfeeding disruption increased with greater levels of support with P values of P = .003, P = .04, and P < .001, respectively. We found that the impact on patient-reported outcomes varied by level of support, as defined here, among children hospitalized with bronchiolitis, with significant impacts being in areas of caregiver bonding, caregiver holding, and breastfeeding.

High Variability in the Duration of Chest Compression Interruption is Associated With Poor Outcomes in Pediatric Extracorporeal Cardiopulmonary Resuscitation.

To determine the association between chest compression interruption (CCI) patterns and outcomes in pediatric patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). Cardiopulmonary resuscitation (CPR) data were collected using defibrillator-electrode and bedside monitor waveforms from pediatric ECPR cases between 2013 and 2021. Duration and variability of CCI during cannulation for ECPR was determined and compared with survival to discharge using Fishers exact test and logistic regressions with cluster-robust se s for adjusted analyses. Quaternary care children's hospital. Pediatric patients undergoing ECPR. None. Of 41 ECPR events, median age was 0.7 years (Q1, Q3: 0.1, 5.4), 37% (15/41) survived to hospital discharge with 73% (11/15) of survivors having a favorable neurologic outcome. Median duration of CPR from start of ECPR cannulation procedure to initiation of extracorporeal membrane oxygenation (ECMO) flow was 21 minutes (18, 30). Median duration of no-flow times associated with CCI during ECMO cannulation was 11 seconds (5, 28). Following planned adjustment for known confounders, survival to discharge was inversely associated with maximum duration of CCI (odds ratio [OR] 0.91 [0.86-0.95], p = 0.04) as well as the variability in the CCI duration (OR 0.96 [0.93-0.99], p = 0.04). Cases with both above-average CCI duration and higher CCI variability ( sd > 30 s) were associated with lowest survival (12% vs. 54%, p = 0.009). Interaction modeling suggests that lower variability in CCI is associated with improved survival, especially in cases where average CCI durations are higher. Shorter duration of CCI and lower variability in CCI during cannulation for ECPR were associated with survival following refractory pediatric cardiac arrest.

Applicability of perfusion weighted imaging in evaluating the curative effect of endostar combined with neoadjuvant chemotherapy in advanced cervical cancer

Purpose: To investigate the applicability of perfusion-weighted imaging (PWI) in evaluating the curative effect of endostar (EN) combined with neoadjuvant chemotherapy (NAC) in advanced cervical cancer.&#x0D; Methods: Between January 2021 and December 2022, 85 patients from Gansu Provincial Maternity and Child-care Hospital, China with advanced cervical cancer received NAC intravenously and underwent pre and post-chemotherapy PWI. Neoadjuvant chemotherapy (NAC) consisted of paclitaxel (135 - 175 mg/m2) and carboplatin (300 - 400 mg/m2). The NAC regimen comprised three courses, with each course lasting three weeks. General data, gross tumor volume (GTV), maximum signal intensity loss rate (MSILR), tumor regression rate (TRR), and post-chemotherapy MSILR reduction were compared between effective and non-effective groups.&#x0D; Results: There was a significant difference in International Federation of Gynecology and Obstetrics (FIGO) staging, pathological types and proportion of lymph node metastasis between effective and non-effective groups (p &lt; 0.05). At the end of 3 cycles of chemotherapy, ORR was 72.94 %. After treatment with EN combined with NAC, GTV and MSILR in effective group were significantly lower compared to non-effective group (p &lt; 0.05). After chemotherapy, the mean relative ratio (MRR) and MSILR in effective group were significantly higher compared to non-effective group (p &lt; 0.05). Also, MSILR before treatment (EN combined with NAC) was positively correlated with TRR after chemotherapy in patients with advanced cervical cancer (p &lt; 0.05).&#x0D; Conclusion: Perfusion-weighted imaging effectively changes tumor volume in patients with advanced cervical cancer after treatment with EN combined with NAC, and this has high application in evaluating the drug’s curative effect.

The identification of WHO emergency signs in children by nurses at triage in an emergency department

ABSTRACT Background The World Health Organization recommends the use of a three-tier triage system to recognise a sick child in low- and middle-income countries. The three tiers are based on standardised emergency and priority signs. No studies have evaluated the prevalence or reliable detection of these emergency signs. Aims To determine the prevalence of WHO emergency signs and the underlying causes, and to determine whether nurses could reliably detect these signs in children presenting to the emergency department at Port Moresby General Hospital in Papua New Guinea. Methods A prospective study measured inter-rater agreement between nurses at triage and a blinded second assessor trained in paediatrics. Results The prevalence of emergency signs was 16.7%: 32 of 192 children had these signs at presentation; 18 (9.4%) had severe respiratory distress; 10 (5.2%) had severe dehydration; and 3 (1.6%) had convulsions. There was an acceptable inter-rater agreement between nurses and doctors (Cohen’s Kappa score >0.4) for some signs: subcostal recession, intercostal recession, nasal flaring, lethargy, weak volume pulses, convulsions, sunken eyes and a poor conscious state. Obstructed breathing, cyanosis, tracheal tug and cold hands and feet were less commonly detected and had poor inter-rater agreement (Kappa score <0.4). Conclusions Effective screening at triage can enable prompt emergency treatment by nurses and can help focus doctors’ attention on children who require it most. There is a need for additional training in the identification of some emergency signs. Abbreviations CED: children’s emergency department; ETAT: emergency triage assessment and treatment; HCC: Hospital Care for Children; PMGH: Port Moresby General Hospital; PNG: Papua New Guinea; WHO: World Health Organization

Pediatric resident use, perceptions, and desires for improvement of a clinical secure messaging application

BackgroundHospitals are transitioning away from traditional pagers to secure text messaging (STM) applications. STM is perceived to improve efficiency and accessibility. There is limited research on user's impressions of how STM impacts patient safety, provider wellness, and quality of patient care. ObjectivesTo understand the use and perceptions of a clinical STM by pediatric residents at a free-standing quaternary care children's hospital. MethodsA survey was conducted of pediatric residents regarding their experience with Diagnotes®. Demographic data were obtained along with use patterns, ability to perform tasks, and perceptions of intended purpose. Further questions evaluated agreement with communication strategies and satisfaction with features. Three open-ended questions asked about experience where STM impacted (1) patient care coordination and (2) patient safety. A final question asked for any additional STM feedback. ResultsOf 169 surveys, there were 112 respondents (66.3 % response rate). Respondents unanimously endorsed daily STM use on their personal mobile devices with good knowledge of basic features. Respondents were overall satisfied with Diagnotes® (73.9 %) including the ability to communicate efficiently (84.8 %) and effectively (79.5 %). Yet only 32.1 % were satisfied with Diagnotes® training. Only 59.5 % believed Diagnotes® was appropriate for urgent patient care needs and only 43.2 % believed its purpose was to inform the team of patient emergencies. Key qualitative themes included improved coordination of patient care tasks through STM, but there were concerns raised around sending and receiving messages, the additional cognitive burden placed by STM, and differences in culture of use that created conflict. ConclusionsDiagnotes® is viewed positively including use for effective coordination of patient care and familiarity of functions of Diagnotes®. Barriers included unclear interprofessional expectations for use. Future research should incorporate a broad range of healthcare professionals' perceptions and co-creation of STM best practice guidelines for use, including around urgent or emergent patient care issues.

Analysis of ultrasonic imaging changes and factors related to malignant transformation in postmenopausal patients with endometrial polyps.

To examine the ultrasonic changes in postmenopausal endometrial polyps and analyze factors related to their malignant transformation. This retrospective study analyzed clinical data from 200 postmenopausal patients with endometrial polyps treated at Jinan Maternity and Child Care Hospital and Pingyin Hospital of Traditional Chinese Medicine from December 2020 to December 2023. All patients underwent pathological biopsies to diagnose the nature of the endometrial polyps. This study compared the clinical and ultrasonic imaging features of these patients and analyzed factors influencing the malignant transformation of postmenopausal endometrial polyps. Pathological findings classified 160 patients (80.00%) into the benign group and 40 patients (20.00%) into the malignant group. Significant differences were noted in endometrial thickness, polyp diameter, heterogeneity of lesion echogenicity, and vascularization between the groups (all P<0.05). The malignant group exhibited notably higher blood flow (Grade II+III constituted 70.00% compared to 29.38% in the benign group, P<0.05). The time average velocity (TAV), pulse index (PI), and resistance index (RI) were significantly lower in the malignant group (all P<0.05). The area under curve (AUC) values for TAV, PI, and RI in diagnosing malignant endometrial polyps were 0.754, 0.713, and 0.771, respectively. Increased body mass index (BMI), irregular premenopausal menstruation, and ≥2 occurrences of postmenopausal bleeding were identified as risk factors for malignant transformation (all P<0.05). These six indicators were used to create a predictive model for malignant transformation, achieving an AUC of 0.942. Malignancy in postmenopausal endometrial polyps is uncommon, yet distinct differences exist in the transvaginal color Doppler ultrasound characteristics between benign and malignant cases. Factors such as increased BMI, irregular premenopausal menstruation, and ≥2 occurrences of postmenopausal bleeding significantly contribute to the risk of malignant transformation. These findings, combined with ultrasound features, provide a robust basis for screening and monitoring these patients.

Effects of thyroid hormones modify the association between pre-pregnancy obesity and GDM: evidence from a mediation analysis.

Conflicting associations have been noted between thyroid function and gestational diabetes mellitus (GDM), with indications that pre-pregnancy BMI might influence these relationships. This study aims to examine the effect of thyroid hormone indices and their mediation role on the risk of GDM. Pregnant women in our study were recruited from the Zhoushan Pregnant Women Cohort, Zhejiang Province, China. Participants who had their first prenatal follow-up and measured thyroid biomarkers in the first trimester, and oral glucose tolerance test (OGTT) records in the second trimester were eligible for inclusion in this study. The data were extracted from the Electronic Medical Record System database, at Zhoushan Maternal and Child Care Hospital. Maternal information about sociodemographic and health-related characteristics was extracted from the dataset. A unique personal identification number was provided to link both datasets. Multivariate logistic regression models were applied to investigate the correlations between thyroid hormone indices with GDM. The interaction effects of first-trimester thyroid hormone indices with pre-pregnancy BMI on GDM risk using a generalized linear regression model. Furthermore, the mediation analysis was used to explore the potential mediating effects of thyroid hormone indices on the relationship between pre-pregnancy BMI and GDM. Overall, 5895 pregnant women were included in this study. The first-trimester FT4, thyroid feedback quantile-based index (TFQI), thyrotropin index (TSHI) and thyrotroph thyroxine resistance index (TT4RI) levels were negatively associated with fasting blood glucose (FBG) and postprandial blood glucose (PBG2H) in the second trimester (all P<0.05); FT3 and the FT3-to-FT4 ratio levels were positively associated with PBG1H and PBG2H in the second trimester (all P<0.05). Moreover, there were significant correlations between the highest quartile FT4, FT3, FT3-to-FT4 ratio, TSHI, and TFQI with GDM (all P < 0.05). The mediating effect of thyroid hormone parameters was 24.9% on the association between pre-pregnancy BMI and GDM. In conclusion, the low FT4, high FT3-to-FT4 ratio, and low TFQI in the first trimester significantly increase the risk of GDM and should be given more attention. Furthermore, increased pre-pregnancy BMI might partially increase the risk of GDM by influencing the body's thyroid function.

Patient and Technical Factors Associated with Difficult Arterial Access and Ultrasound Use in the Operating Room.

Arterial catheterization enables continuous hemodynamic monitoring but has been shown to cause severe complications, especially when multiple attempts are required. The aim of this study was to explore what factors were associated with multiple attempts and ultrasound use in the operating room. We performed a retrospective analysis of patients who had arterial catheters inserted at a tertiary care children's hospital from January 2018 to March 2022, identifying clinical factors that were associated with both outcomes. A total of 3946 successful arterial catheter insertions were included. Multivariable analysis showed multiple attempts were associated with noncardiac surgery: pediatric (OR: 1.79, 95% CI: 1.30-2.51), neurologic (OR: 2.63, 95% CI: 1.89-3.57), orthopedic (OR: 3.23, 95% CI: 2.27-4.55), and non-radial artery placement (OR: 5.00, 95% CI: 3.33-7.14) (all p < 0.001). Multivariable analysis showed ultrasound use was associated with neonates (OR: 9.6, 95% CI: 4.1-22.5), infants (OR: 6.98, 95% CI: 4.67-10.42), toddlers (OR: 6.10, 95% CI: 3.8-9.8), and children (OR: 2.0, 95% CI: 1.7-2.5) compared to teenagers, with cardiac surgery being relative to other specialties-pediatric (OR: 0.48, 95% CI: 0.3-0.7), neurologic (OR: 0.27, 95% CI: 0.18-0.40), and orthopedic (OR: 0.38, 95% CI: 0.25-0.58) (all p < 0.001). In our exploratory analysis, increased odds of first-attempt arterial catheter insertion success were associated with cardiac surgery, palpation technique, and radial artery placement. Younger patient age category, ASA III and IV status, cardiac surgery, and anesthesiologist placement were associated with increased odds of ultrasound use.

Targeting zero medication administration errors in the pediatric intensive care unit: A Quality Improvement project

BackgroundMedication errors and adverse drug events have a significant impact on mortality and morbidity among hospitalized children, and are more likely to occur in critical care settings due to the fast-paced environment and patient vulnerability. There is no exception to this rule in our pediatric intensive care unit, a 28-bed unit at a tertiary care children's hospital in Riyadh, Saudi Arabia. Problem assessmentA medication administration error rate of 6.25–8.05/1000 patient days was reported in our unit (48 errors), taking into account only errors that reached patients. Toward improving patient safety, a project was launched to reduce medication errors. DesignMultidisciplinary quality improvement team reviewed baseline data and analyzed medication errors that occurred in 2019. Five Plan-Do-Study-Act cycles were implemented. As an outcome measure, the medication error rate was monitored. ResultsThe outcome measure of medication administration error rates was monitored quarterly. An improvement of 75% during the first quarter of 2021 to a rate of zero medication errors/1000 patient days during the first quarter of 2022. A decrease in medication errors was attributed to improved situational awareness and increased compliance with assisted technology. ConclusionMedication errors can be decreased by deploying various interventions utilizing human- and technology-based approaches. When it comes to reducing medication errors in the pediatric intensive care unit, a multidisciplinary approach is paramount. Implications for clinical practiceThis study suggests several ways to reduce medication errors. Implementing information technology systems and involving pharmacists in medication management can help prevent errors. Enhancing teamwork, communication, and collaboration among healthcare professionals is also important. Clinical risk management strategies, nursing interventions, and adherence to medication safety guidelines are essential, especially for pediatric and neonatal populations. Considering these clinical implications can guide healthcare professionals and organizations in addressing medication errors and enhancing patient safety.

Environmental impact on pediatric epistaxis and the utility of diagnostic studies: A single-institutional review

ObjectivesPediatric epistaxis is a multifactorial disease entity. The objective of this study is to determine the socioeconomic and air-quality contributions to pediatric epistaxis. The study also evaluates the utility of diagnostic lab work as a predictor of bleeding rates and need for operative intervention. MethodsA case series of pediatric patients treated in an outpatient Otolaryngology clinic at a tertiary care children's hospital in 2021 for epistaxis was performed. Patients with nasal bone trauma (n = 8), consult while inpatient (n = 7), and those with nasal masses (n = 2) were excluded; 181 patients met inclusion criteria. Demographic, clinical, socioeconomic, and air quality (tropospheric ozone, particulate matter) data were recorded. Associations with persistent bleeding and operative interventions were evaluated using logistic regression, Wilcoxon rank-sum, and Spearman rank correlation. ResultsOf the 181 patients, 75 (41.4%) were female. Forty-six of 181 (25.4%) had associated allergic symptoms. Twenty-six patients had allergy testing; 14/26 (53.8%) of these had positive results. Re-bleeding was more common in those with allergic symptoms (OR: 2.42, 95% CI: 1.22–4.78, p = 0.01). Patients with re-bleeding lived in counties with more days with ozone over the US standard (median 5 days, range 0–32 days) compared with those with no re-bleeding (median 3 days, range 0–32 days, p = 0.007). There was also an association between the number of visits for re-bleed and percent below poverty level (ρ = 0.259, p = 0.03) as well as the number of days with particulate matter levels over the US standard (ρ = 0.343, p = 0.01). Coagulopathy was present in 9/54 (16.7%) patients, with the majority being Von Willebrand disease (5/54, 9.3%). Easy bruising was not significantly associated with positive lab results. ConclusionsEnvironmental pollution, living in a zip code with more residents below the poverty level, and allergic rhinitis were positively associated with recurrent epistaxis. Understanding the geographic background of presenting patients may help direct workup and treatment options.

Current Pediatric Tertiary Care Practices Following Adenotonsillectomy: An Update.

Adenotonsillectomy is a common procedure performed in children, and the practice patterns at academic centers have been evolving with the publication of updated societal guidelines. In this study, we assess perioperative practice patterns at tertiary care children's hospitals for children undergoing adenotonsillectomy. A cross-sectional 18-question survey distributed in July of 2022 recruited responses through August 25, 2022. The division chiefs of 70 pediatric otolaryngology groups at tertiary care children's hospitals across the United States and Canada were surveyed. Division chiefs submitted survey responses on behalf of the group practice patterns for children undergoing adenotonsillectomy. The main measure was survey responses from the division chiefs of pediatric otolaryngology reporting group practice. The survey response rate was 46%. Eighty-eight percent of groups reported an official adenotonsillectomy admission policy. Commonly reported admission criteria included age (93%) and obesity (59%). Eighty-eight percent of groups defined severe obstructive sleep apnea as apnea-hypopnea index ≥10. Only 41% of groups required a child to be observed sleeping on room air prior to ambulatory discharge. Ninety-seven percent of groups reported routinely obtaining preoperative polysomnography in a variety of clinical settings. Many children's hospitals report an official admission policy following adenotonsillectomy. Despite a decade passing since the initial publication of the American Academy of Otolaryngology-Head and Neck Surgery clinical practice guidelines, there remains great variability in the practice patterns for both preoperative polysomnography and postoperative monitoring and admission. These results highlight an opportunity for an improved unified approach to perioperative pediatric adenotonsillectomy practice. 5 Laryngoscope, 134:2931-2936, 2024.

Attitudes of physicians in a tertiary care children's hospital in the face of death.

Introduction. For physicians, death involves an intricate analysis that determines their attitude towards the patient. Objectives. 1) To describe the attitudes towards death among medical staff working at a children's hospital. 2) To explore factors associated with such attitudes. Population and methods. Cross-sectional, survey study. The physicians working at a tertiary care children's hospital completed the Questionnaire of attitudes towards death (QAD). Sociodemographic variables, professional category, work setting, having witnessed the death of patients, self-perception of a positive attitude towards death, and attitude towards death according to the QAD were studied. Results. Between June 1st, 2021 and June 1st, 2022, 362 participants were included; mean age: 39.88 years (± 11.56), health care experience: 14.06 years (± 11.97). A positive attitude was observed in 35 (9.67%). A statistical significance was observed for a greater probability of a positive attitude among those who were ≥ 40 years old (p = 0.02, 95% CI: 1.1-3.9), had health care experience for ≥ 14 years (p = 0.042, 95% CI: 1-4.1), had a religious belief (p = 0.003, 95% CI: 1.4-10.5), actively practiced their religion (p < 0.001, 95% CI: 1.6-6.9), and had a positive self-perception in the face of death (p = 0.002, 95% CI: 1.7-30.8). Conclusions. A positive attitude towards death was observed in 9.67% of surveyed participants.Associated factors were age ≥ 40 years, health care experience for ≥ 14 years, religious belief, active religious practice, and self-perception of a positive attitude towards death.

Racial, ethnic and language disparities in healthcare utilization in pediatric patients following tonsillectomy

ImportanceTonsillectomy is one of the most common surgical procedures performed in the United States. However, there is little known about the intersectionality of race, ethnicity, and language and how these factors influence post-tonsillectomy outcomes such as ED utilization and hospital readmission rates. ObjectiveTo examine disparities in emergency department (ED) utilization and hospital readmissions for post-tonsillectomy complications based on insurance status, patient race, ethnicity and language spoken. DesignThis was retrospective cohort over four years. SettingTertiary Care Children's Hospital. ParticipantsAll children (n = 10,215) who underwent tonsillectomy or adenotonsillectomy at a tertiary children's hospital from January 2015 to December 2018 were identified and included. There were no exclusion criteria. ExposureThe exposure of interest was tonsillectomy. Main outcomes and measuresOutcomes and variables of interest were defined prior to data collection. The primary outcome of this study was emergency department (ED) utilization defined as any ED or urgent care visit within 21 days of the tonsillectomy for surgery-related concerns. The secondary outcome of this study was readmissions following tonsillectomy. ResultsA total of 10215 pediatric patients (median age, 6 years; 5096 [50 %] male) who underwent tonsillectomy were included in the analysis. 13 % of patients presented to the ED with surgery-related complaints. Among English proficient patients, multi-racial patients were the only group with an elevated odds of ED utilization (OR:1.5, 95 % CI: 1.2, 1.9). Non-English language preference (NELP) patients of Black, Hispanic, Asian, and American Indian/Alaskan Native race/ethnicity also had elevated odds of ED use post-tonsillectomy compared to non-Hispanic White English proficient patients. Six percent of all patients had an unplanned hospital readmission. Asian patients with non-English language preference had 2.1 times the odds of readmission (95 % CI: 1.2, 3.6); and were disproportionately admitted for post-tonsillectomy hemorrhage. Conclusionsand Relevance: Language disparities in ED use and readmission persist after adjusting for risk factors. Non-English language preference populations have a higher rate of ED utilization, especially for minor complications. Disparities may result from differential health literacy or predispositions to complications. Future directions include additional research on mechanisms and targeted interventions to increase education and access to language-appropriate resources.

What do parents think about the quality and safety of care provided by hospitals to children and young people with an intellectual disability? A qualitative study using thematic analysis.

Children with intellectual disability experience patient safety issues resulting in poor care experiences and health outcomes. This study sought to identify patient safety issues that pertain to children aged 0-16 years with intellectual disability admitted to two tertiary state-wide children's hospitals and a children's palliative care centre; to describe and understand these factors to modify the Australian Patient Safety Education Framework to meet the particular needs for children and young people with intellectual disability. Parents of children with intellectual disability from two paediatric hospitals and a palliative care unit participated in semi-structured interviews to elicit their experiences of their child's care in the context of patient safety. Thirteen interviews were conducted with parents from various backgrounds with children with intellectual, developmental and medical diagnoses. Eight themes about safety in hospital care for children and young people with intellectual disability emerged from thematic analyses: Safety is not only being safe but feeling safe; Negative dismissive attitudes compromise safety, quality and care experience; Parental roles as safety advocates involve being heard, included and empowered; Need for purposeful and planned communication and care coordination to build trust and improve care; Systems, processes and environments require adjustments to prevent patient safety events; Inequity in care due to lack of resources and skills, Need for training in disability-specific safety and quality issues and Core staff attributes: Kindness, Patience, Flexibility and Responsiveness. Parents highlighted the dilemma of being dismissed when raising concerns with staff and being required to provide care with little support. Parents also reported a lack of comprehensive care coordination services. They noted limitations within the healthcare system in accommodating reasonable adjustments for a family and child-centred context. The development of an adapted Patient Safety Education Framework for children with intellectual disability should consider ways for staff to transform attitudes and reduce bias which leads to adaptations for safer and better care. In addition, issues that apply to quality and safety for these children can be generalised to all children in the hospital. Parent advocates in the project advisory team were shown the questions to determine their appropriateness for the interviews.

1668. Antibiotic Usage Trends Following Implementation of Handshake Stewardship at a Tertiary Care Children's Hospital

Abstract Background Antimicrobial stewardship was implemented at the University of Iowa Stead Family Children’s Hospital in November 2018 principally through handshake stewardship with pediatric intensive care and hospitalist teams. We sought to evaluate the impact of this intervention on the use of select antibiotics targeting P. aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA). Methods Use of select anti-pseudomonal (cefepime, piperacillin/tazobactam and meropenem) and anti-MRSA (vancomycin, linezolid and daptomycin) agents within our pediatric intensive care unit (PICU) and pediatric wards (L9 and L10) was retrospectively reviewed. Mean days of therapy (DOT) per 1000 patient days (PD) was aggregated and trended annually from January 2018 until December 2022. Simple linear regression analysis was conducted to detect significant changes in antimicrobial use over time. Results Use of anti-pseudomonal and anti-MRSA agents in the PICU declined by 40% and 29%, an absolute reduction of 99 and 60 DOT/1000 PD, respectively (P-value: 0.0366 and 0.0210, respectively) (Figure 1). Use of anti-MRSA agents on L10 declined by 52% (absolute reduction of 53 DOT/1000 PD; P-value: 0.0263), but only declined by 6% on L9 (Figure 2, Figure 3). Use of anti-pseudomonal agents on L10 declined by 56% (absolute reduction of 44 DOT/1000 PD; P-value: 0.0522), but only declined by 10% on L9 (Figure 2, Figure 3). Figure 1: Mean Days of Therapy Per 1000 Patient Days of Anti-Pseudomonal and anti-MRSA Usage in the PICU Figure 2: Mean Days of Therapy Per 1000 Patient Days of Anti-Pseudomonal and anti-MRSA Usage on L9 Figure 2: Mean Days of Therapy Per 1000 Patient Days of Anti-Pseudomonal and anti-MRSA Usage on L10 Conclusion Implementation of a handshake stewardship intervention strategy was associated with decreasing DOT of select antibacterial agents. The inability to significantly impact antimicrobial usage on L9 was potentially impacted by this being a mixed unit with subspecialty and surgical services. Expansion of handshake stewardship to subspecialty and surgical services may further reduce usage on mixed units. Disclosures All Authors: No reported disclosures

1618. Assessing and Improving Accurate Diagnosis and Reporting of Congenital Syphilis in a Tertiary Care Children's Hospital

Abstract Background Congenital syphilis (CS) occurs due to transplacental passage of active infection to the fetus during pregnancy. Clinical presentation ranges from asymptomatic to severe permanent disability. Nationally, the incidence and prevalence of syphilis among cisgender females ages 15-44 have increased, with proportional increases in rates of CS. In 2020, 19 cases of CS were reported to the Chicago Department of Public Health (CDPH), a 138% increase from 2019 (8 cases). There are circumstances where infants with a non-reactive rapid plasma reagin (RPR-) may potentially contract syphilis in the context of inadequate maternal treatment per national guidelines. (Figure 1) Currently, only infants with RPR reactivity (RPR+) are reported to CDPH, potentially underestimating the true incidence. Our project sought to identify RPR- infants who received treatment to improve reporting to CDPH, more accurately reflect the prevalence of CS in Chicago, and ultimately guide interventions to reduce and eliminate CS.Figure 1:2021 Center for Disease Control (CDC) Possible Congenital Syphilis Definition Methods Data was collected via electronic medical record (EMR) review for infants born at Comer Children’s Hospital in Chicago, IL between 2012 and 2022, filtered using ICD-9 code (090) and ICD-10 code (A50.9) for CS. Infants were excluded if diagnosis code was used in error, there was no RPR result, or diagnosis occurred at an outside institution. (Figure 2) Infants were stratified as having CS with RPR+ or RPR-. Retrospectively, each infant was also classified with a diagnosis of less likely CS, possible CS, and proven CS per national guidelines.Figure 2:Patient Stratification by ICD-9 and ICD-10 Code for Congenital Syphilis and RPR Reactivity. RPR = Rapid Plasma Reagin Results 68 infants with CS were identified. 57 infants received IV PCN with diagnoses of proven or possible CS (84%). 51 (75%) patients were RPR+ and 17 (25%) were RPR-. (Figure 3) Of the 17 RPR-, 11 had a diagnosis of possible CS (65%) and received IV PCN while 6 (35%) had less likely CS and received one dose of intramuscular (IM) PCN (Table 1). None of the RPR- infants were reported to CDPH.Figure 3:Total Number of Congenital Syphilis Cases Based on CDC Definition. CS = Congenital Syphilis, CDC = Center for Disease ControlTable 1:Total Number of Days of Intravenous or Intramuscular Penicillin Administration per RPR reactivity.. Aq PCN = Aqueous Penicillin G, Ben PCN = Benzathine Penicillin G, IM = Intramuscular, IV = Intravenous Conclusion In this retrospective analysis, reporting CS based solely on a reactive infant RPR leads to underreporting. As we confront the rising incidence of CS, (Figure 4) it is critical that we have a complete understanding of the epidemiology which may lead to increased support for public health initiatives focused on decreasing and eliminating CS.Figure 4:Timeline of Total CS and RPR- CS Cases at Hospital per Year. CS = Congenital Syphilis Disclosures Allison H. Bartlett, MD, MS, CVS/Caremark: Honoraria Jessica Ridgway, MD, Gilead Sciences: Expert Testimony