Freestanding Children's Hospital Research Articles

Increased physiologic dead space fraction is associated with mortality after comprehensive stage 2 operation.

Our objective was to assess the predictive value of physiologic dead space fraction for mortality in patients undergoing the comprehensive stage 2 operation. This was a single-centre retrospective observational study conducted at a quaternary free-standing children's hospital specialising in hybrid palliation of single ventricle cardiac disease. 180 patients underwent the comprehensive stage 2 operation. 76 patients (42%) underwent early extubation, 59 (33%) standard extubation, and 45 (25%) delayed extubation. We measured time to extubation, post-operative outcomes, length of stay and utilised Fine gray models, Youden's J statistic, cumulative incidence function, and logistic regression to analyse outcomes. Delayed extubation group suffered significantly higher rates of mortality (31.1% vs. 6.8%), cardiac arrest (40.0% vs. 10.2%), stroke (37.8% vs. 11.9%), and need for catheter (28.9% vs. 5.1%) and surgical intervention (24.4% vs. 8.5%) (P < 0.001). Physiologic dead space fraction was significantly higher in the delayed extubation group and in non-survivors with a value of 0.3, which was found to be the discriminatory point by Youden's J statistic. For a 0.1 unit increase in physiologic dead space fraction on post-operative day 1, the odds of a patient expiring increase by a factor of 2.26 (95% CI 1.41-3.97, p < 0.001) and by a factor of 3.79 (95% CI 1.65-11.7, p 0.01) on post-operative day 3. Delayed extubation impacts morbidity and mortality in patients undergoing the comprehensive stage 2 operation. Increased physiologic dead space fraction in the first 60 hours after arrival to the ICU is associated with higher mortality.

Pediatric Tracheostomy Education Program Structures, Barriers, and Support: A Nationwide Survey of Children's Hospitals.

Safe discharge for children with tracheostomies requires caregivers to be competent in tracheostomy management, including emergency interventions. Inpatient pediatric units are tasked with preparing families for discharge, yet variations exist in the standards of tracheostomy education across institutions. To address this gap, we aimed to describe the inpatient tracheostomy education programs in children's hospitals across the United States. This is a cross-sectional study conducted between May and July 2022. We distributed an online survey to a purposeful sample of representatives from participating children's hospitals. The 42-item survey evaluated various aspects of tracheostomy education, including teaching strategies, timing of education, operational support, and overall program structure. Descriptive statistics were generated, and researchers reviewed open-ended items to identify themes. Thirty-seven institutions participated, 26 of which were free-standing children's hospitals. All programs surveyed conducted bedside checkoffs, required a rooming-in period, and provided tracheostomy cardiopulmonary resuscitation and low-fidelity simulation for emergency teaching. Programs varied in the order of education and the type of support received. Many programs lacked a postdischarge follow-up structure and the majority evaluated program effectiveness with readmission rates. Lack of private-duty nursing was the primary barrier to discharge, followed by family availability and reluctance to participate in education. The program structure and support variations suggest that more investigation is needed in discharge education and postdischarge follow-up for children with tracheostomies. A national guideline for tracheostomy education and identification of standardized quality metrics for program evaluation would benefit current and emerging programs.

The impact of current pediatric anesthesiology fellows shortfall on freestanding children's hospitals and practices

The pediatric anesthesiology workforce is currently facing a critical shortage, which will have significant consequences for patient care and the healthcare system as a whole. The workforce is aging, and despite increasing numbers of anesthesiology residents, fewer graduates are entering the field of pediatrics. It should also be noted that fewer medical school graduates are entering pediatrics as well. This situation raises concerns about the availability of specialists and the training of future physicians. To address this shortage, a comprehensive strategy is urgently needed, including outreach, mentorship, financial incentives, and policy changes to attract and retain new talent in pediatric anesthesiology. Immediate intervention is necessary to prevent a severe impact on the availability and quality of pediatric anesthesia care.

Factors Affecting Length of Stay for Children Hospitalized After Pediatric Surgical Procedures.

Understanding the postoperative length of stay (LOS) by surgical procedure is important for hospital medicine clinicians involved in surgical co-management. We assessed variation in postoperative LOS for children after elective surgical procedures and risk factors for prolonged LOS. This study is a retrospective analysis of pediatric patients undergoing elective surgical procedures between January 1, 2018 and October 1, 2021 with postoperative hospitalization for recovery at a freestanding children's hospital. The postoperative LOS (number of days) was compared across types of surgery and by the number of chronic conditions (assessed with the Agency for Healthcare Research and Quality Condition Indicator system) using multivariable quantile regression. The median (interquartile range) LOS across all 347 types of surgical procedures combined was 2 (interquartile range 1-4). Surgical procedures (n = 85) with a median LOS between 3.0 and <5.0 days (eg, spinal fusion, Chiari decompression) accounted for 20.9% of all hospitalizations (N = 12 139) and 23.1% of all postoperative bed days. Procedures (n = 46) with a median LOS of ≥5.0 days (eg, femoral osteotomy, bladder reconstruction) accounted for 15.0% and 46.8% of all hospitalizations and bed days, respectively. After controlling for the type of procedure, having ≥4 (versus none) chronic conditions was significantly associated with experiencing a prolonged LOS (90th percentile: 5.2 days); patients with 4 to 6, versus no, chronic conditions stayed a median of 1.4 (95% confidence interval [CI] 0.7-2.2) days longer, those with 7 to 9 chronic conditions stayed a median of 1.9 (95% CI 1.0-2.7) days longer, and those with ≥10 chronic conditions stayed a median of 4.0 (95% CI 3.3-4.7) days longer. Hospital medicine clinicians can use the type of surgery in combination with the number of chronic conditions to estimate postoperative LOS after elective surgical procedures in children.

Parental Health Literacy and Acute Care Utilization in Children With Medical Complexity.

Health literacy is the ability to find, understand, and use information and services to inform health-related decisions and actions. Inadequate health literacy is associated with health disparities, poor health outcomes, and increased emergency department (ED) visits and hospitalizations. Children with medical complexity (CMC) have high rates of acute health care utilization. We examined the association of parental health literacy with acute care utilization and costs in CMC. This cross-sectional study included parents of CMC receiving primary care at a free-standing children's hospital. We measured parental health literacy using the Single Item Literacy Screener, which measures the assistance needed to read health care materials. Our main predictor was parental health literacy, categorized as adequate versus inadequate. In a sensitivity analysis, we categorized health literacy as never needing assistance versus needing any assistance. Main outcomes were annual ED visits, hospitalizations, and associated costs. Of the 236 parents of CMC, 5.5% had inadequate health literacy. Health literacy was not associated with acute care utilization or associated costs. In our sensitivity analysis, CMC whose parents need any assistance to read health care materials had 188% higher ED costs (adjusted rate ratio 2.88 [95% confidence interval: 1.63-5.07]) and 126% higher hospitalization costs (adjusted rate ratio 2.26 [95% confidence interval: 1.49-3.44]), compared with CMC whose parents never need assistance. Inadequate parental health literacy was not associated with acute care utilization. However, CMC of parents needing any assistance to read health materials had higher ED and hospitalization costs. Further multicenter studies are needed.

Impact and learner perspectives of a spaced-education platform to assess hand hygiene auditor competency.

To ensure whether spaced education, which increases long-term knowledge retention, could be integrated into auditor competency assessment. Quality improvement project. Academic, freestanding children's hospital. Hand hygiene (HH) auditors. We enrolled trained HH auditors in an online spaced-education platform to assess mastery of knowledge, delivering 46 unique questions at spaced intervals followed by rationale; we retired questions after 3 correct answers. An e-mailed 10-item survey gauged participant satisfaction with the program. The Wilcoxon signed-rank test was used to compare change in median knowledge score from first to final attempt. A total of 12,120 questions were attempted by 126 auditors, and 49 (39%) completed the entire course. Median knowledge score increased significantly by 10.5 percentage points (IQR 4-15) between first and final attempts (P < 0.001). Thirty auditors (27%) responded to the survey. The majority agreed the number and complexity of questions were appropriate (57% and 67%, respectively). Eighty-seven percent reported the platform easy to navigate, and 77% agreed adequate time was provided for completion. Free-text suggestions included delivering fewer questions at a narrower spacing interval over a shorter time frame because of competing work demands. Auditor knowledge of HH indications and technique is critical to ensuring data validity. A spaced-education competency program improved HH auditor knowledge in the short term. Completion rate was low, and some participants expressed a desire for fewer questions over a shorter time frame. This study offers insight into ways to optimize spaced education as a potential tool for HH competency assessment.

Vascular Access for Renal Replacement Therapy in Neonates and Infants: A Single Center Experience

IntroductionNeonatal renal replacement therapy (RRT) is a treatment modality used for severe kidney failure. Historically, its use has been limited in small infants due to circuits with large extra-corporeal volumes that require large double lumen vascular catheters. We sought to review our institution's experience with vascular access and overall survival in infants who receive RRT. MethodsA retrospective chart review of infants less than 5 kg (kg) was performed at our free-standing children's hospital from January 2016 to July 2023. We assessed the number of catheters used per patient, location of catheter placements, size of catheter, duration of treatment, reasons for line removal, and mortality. ResultsA total of 93 neonatal patients were identified who underwent RRT. Thirty-two patients (34.4%) required more than one catheter, with a total of 145 catheters placed for this cohort. The median (IQR) weight at insertion was 3.3 kg (2.7–4.0). The most common location for placement was the right internal jugular vein (n = 114, 78.6%). Patients required catheters for RRT for a median (IQR) of 16 days (7–39). Six patients underwent catheter placement at a weight of less than 2 kg. Nineteen total patients went on to peritoneal dialysis (20.4%). Fifty-three patients died during their admission (57.0%). ConclusionTo our knowledge this is the largest review of catheter use for RRT in infants within an intensive care unit and it reveals the success in treating renal failure in even the smallest infants. Level of EvidenceIV, Treatment Study.

Palliative Care for Dialysis-Dependent Pediatric Patients: A Survey of Providers, Nurses, and Caregivers.

Dialysis-dependent pediatric patients and their families face significant biopsychosocial burdens and low health-related quality of life. Palliative care consultations can alleviate some degree of suffering for patients and families but remain underutilized within pediatric nephrology. Little is known about how providers, nurses, and caregivers perceive palliative care integration into the multidisciplinary care of dialysis-dependent pediatric patients. This study surveyed pediatric nephrology providers (physicians and advanced practice providers), inpatient pediatric nephrology bedside nurses, and caregivers of dialysis-dependent pediatric patients at a freestanding tertiary care children's hospital in Dallas, Texas. Participants completed a survey regarding knowledge about, experiences with, and perceptions of palliative care in pediatric nephrology. 10 providers, 20 nurses, and 18 caregivers completed the survey. Although 80% of providers and all nurses agreed that palliative care would benefit dialysis-dependent pediatric patients, most believed that palliative care is not as important in pediatric nephrology as it should be. 70% of providers and 45% of nurses believed that they understand the scope of palliative care. 90% of providers and all nurses desired more palliative care education. Of the 22% of caregivers whose child had already received palliative care services, all found the consultation to be helpful. Many providers and nurses worried that a palliative care consultation would signal to families that the nephrology team would be giving up on their child and that their child is approaching the end of life. However, no caregivers thought that a consultation would mean that the nephrology team would be giving up on their child and only 6% worried that it would indicate that their child is approaching the end of life. These data support further palliative care education for pediatric nephrology providers and nurses and more robust and systematic involvement of subspecialty palliative care for dialysis-dependent pediatric patients.

Outpatient Pediatric Palliative Care Development: Guidance on Building Sustainable Programs.

Context: As pediatric palliative care (PPC) expands within institutions and nationally, little guidance is available on building outpatient programs. Objectives: We asked outpatient PPC (OPPC) program leaders in the United States about clinic development experiences to gather advice for growing programs. Methods: As part of a larger OPPC study, 48 freestanding children's hospitals with inpatient PPC programs were invited to complete a survey on OPPC. Self-selected participants were sent a follow-up survey soliciting free-text responses about development experiences. Quantitative data were analyzed with descriptive statistics. Qualitative data underwent inductive content analysis. Results: Thirty-six hospitals completed the initial survey, and 28 (78%) reported practicing clinic-based OPPC. Twenty-two of 28 completed program development questions. More than half (12/22, 55%) recommended a minimum total billable full-time equivalent (FTE) ≥3 before expanding into the outpatient setting. About two-thirds (14/22, 64%) suggested a minimum billable FTE ≥4 for 24/7 coverage. Half (50%) reported that their program grew from subspecialty clinics, most frequently hematology-oncology (10/11, 91%). Half (50%) placed initial limits on referrals, with many restricting schedule availability (7/11, 64%). Six of 12 participants (50%) willing to share more about their development experience completed a follow-up survey, from which three themes emerged: program logistics, expectations and boundaries, and establishing role and workflow. Participants focused advice on slow programmatic growth to optimize sustainability. Conclusion: Program leaders offer tangible guidance informed by their OPPC development experience. Future work is needed to leverage this advice within institutions to promote resilient and sustainable PPC growth.

Two-stage corrective operation for the treatment of pes cavovarus in patients with spina bifida.

Pes cavovarus has an estimated incidence of 8%-17% in patients with spina bifida (SB). The majority of the current literature on surgical treatment of cavovarus feet in children and adolescents includes a variety of diagnoses. There are currently no case series describing a treatment algorithm for deformity correction in this specific patient population. The authors of this study present the results of a retrospective case series performed to assess the radiographic outcomes of two-stage corrective surgery in patients with SB. To assess the radiographic outcomes of a staged operation consisting of radical plantar release followed by osteotomy for pes cavovarus in patients with SB. Retrospective chart review was performed on patients with SB with a diagnosis of pes cavovarus at a freestanding children's hospital who underwent surgical correction of the deformity. Patients were excluded for lack of two-stage corrective operation, nonambulatory status, lack of at least six months follow-up, and age > 18 years at the time of surgery. This resulted in a cohort of 19 patients. Radiographic analysis was performed on 11 feet that had a complete series of preoperative and postoperative weightbearing X-rays. Preoperative and postoperative radiographic outcome measurements were compared using a two-sample t-test. Significant changes between the preoperative and postoperative measurements were seen in Meary's angle, the anteroposterior talo-first metatarsal (AP TMT1) angle, and the talonavicular coverage. Mean values of Meary's angle were 17.9 ± 13.1 preoperatively and 4.7 ± 10.3 postoperatively (P = 0.016). Mean AP TMT1 angle was 20.6 ± 15.1 preoperatively and 9.3 ± 5.5 postoperatively (P = 0.011). Mean talonavicular coverage values were -10.3 ± 9.6 preoperatively and -3.8 ± 10.1 postoperatively (P = 0.025). The two-stage corrective procedure demonstrated efficacy in correcting cavovarus deformity in patients with SB. Providers should strongly consider employing the staged surgical algorithm presented in this manuscript for management of these patients.

Is Routine Pathology Evaluation of Tissue Removed for Fertility Preservation Necessary?

BackgroundFor all fertility preservation (FP) cases at our institution, a biopsy is performed for routine pathology from all gonadal tissue removed. This is not standard at all centers. We reviewed our experience with biopsy for pathological evaluation of ovarian and testicular specimens in FP cases to determine clinical utility. MethodsThe medical records of individuals who underwent ovarian tissue cryopreservation (OTC) or testicular tissue cryopreservation (TTC) between 2011 and 2023 were retrospectively reviewed under an IRB-approved study at a free-standing tertiary care children's hospital. Patient demographics, diagnosis, operative characteristics, and pathology results were collected. ResultsOne-hundred and eighty-three patients underwent OTC, and 134 patients underwent TTC. All patients had their gonadal tissue biopsied for routine pathology. Malignancy was identified in the biopsies of 4 OTC patients (2.2%) and 2 TTC patients (1.5%). Two OTC patients (1.1%) and 2 TTC patients (1.5%) did not have germ cells identified in their biopsy. All OTC and TTC patients and families elected to continue storing tissue for FP after discussion of pathology findings. ConclusionsPathology results provide another data point to help inform patients and their families when making decisions on ovarian or testicular tissue storage and on how tissue may be utilized in the future to restore fertility and/or hormones. There is a low rate of identifying malignancy in gonadal tissue biopsies taken from FP specimens even in patients with known malignancy. However, when malignancy was identified, it could be unexpected and alter the diagnosis and treatment plan significantly for patients. Level of EvidenceIV.

Provider Implicit Racial Bias in Pediatric Sickle Cell Disease.

This study is to (1) assess implicit racial bias among pediatric providers and (2) use virtual patient (VP) vignettes to determine the impact of implicit racial bias on clinical decision-making in pediatric sickle cell disease (SCD) pain care. This cross-sectional study was conducted at a mid-sized, freestanding children's hospital in the northeast. Participants (N = 52) were pediatric SCD providers (87% cisgender female, 90% White, M age = 38.78). Providers completed a demographic questionnaire, the race Implicit Association Test (IAT) with adult and child faces, and a measure of SCD explicit bias (5-point Likert scale). Providers also made clinical decisions for four VP vignettes depicting Black and White youth in the emergency department (ED) with either SCD or cancer pain. Frequency tables were calculated. On the race IAT, providers demonstrated a pro-White implicit bias for both adult (81%) and child (89%) faces. Responses to the explicit bias measure reflected low levels of agreement with negative stereotypes about SCD patients. No significant differences emerged in providers' pain treatment decisions for Black vs. White, or SCD vs. cancer VPs. Findings indicate pediatric providers harbor implicit racial bias similar to the general population. Findings from VP vignettes did not demonstrate that pain treatment decision-making differed based on race or diagnosis. This may be due to standardized protocols and procedures in the pediatric emergency setting. Future research is needed to clarify the role of implicit bias in clinical decision-making and the potential efficacy of treatment protocols in preventing biases from interfering with pediatric SCD pain care.

Parent Perspectives on Social Risk Screening in the PICU.

Health inequities are widespread and associated with avoidable poor health outcomes. In the PICU, we are increasingly understanding how health inequities relate to critical illness and health outcomes. Experts recommend assessing for health inequities by screening for social determinants of health (SDOH) and adverse childhood experiences (ACEs); however, guidance on screening is limited and screening has not been universally implemented. Our study aimed to understand parent perspectives on screening for SDOH/ACEs in the PICU, with the primary objective of determining whether screening would be acceptable in this setting. We conducted a qualitative study using semistructured interviews with a convenience sample of eleven PICU parents between November 2021 and January 2022. Urban, quaternary free-standing children's hospital. Parents of children with a PICU hospitalization between November 2020 and October 2021. None. Domains of interest included experience with and attitudes toward SDOH/ACEs screening, perspectives on addressing needs with/without resources and their relationship to health, and recommendations for screening. Interviews were transcribed verbatim and coded with an inductive approach using thematic analysis and constant comparative methods. Ann & Robert H. Lurie Children's Institutional Review Board approved this study (2021- 4781, Approved September 13, 2021). Ten participants found SDOH/ACEs screening to be acceptable and valuable in the PICU, even for topics without a readily available resource. Participants did not have broad experience with ACEs screening, though all believed this provided the medical team with valuable context regarding their child. Ten participants recommended screening occur after their child has been stabilized and that they are notified that screening is universal. Participants found screening for SDOH/ACES to be acceptable and valuable in the PICU. Families have important insight that should be leveraged to improve the support of unmet needs through the development of strengths-based, parent-informed screening initiatives.

Central lines, aseptic batching services, and infection rates: A pharmacy-led initiative of intravenous tube priming within a NICU.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Central line-associated bloodstream infections (CLABSIs) are hospital-acquired, serious complications that greatly affect many vulnerable neonates throughout their hospital stay. This article describes the implementation of a unique practice in which pharmacy primes continuous infusions through medication tubing for neonatal central lines in a cleanroom at Children's Hospital Colorado - Colorado Springs (CHCO-CSH). This institution is a freestanding children's hospital with a level III neonatal intensive care unit (NICU) that opened in April 2019. Since then, the pharmacy department has been priming central line tubing for continuous infusions for all patients in the NICU. Neonates are at increased risk for developing CLABSIs due to their immature immune systems and frequent need for central line placement. With that in mind, the pharmacy department decided to focus efforts on this population. Pharmacists and pharmacy technicians received training on how to properly prime tubing, document when a patient received a new central line, document if a central line was removed, and record when new tubing was due based on a department policy. This novel, pharmacy-led priming procedure resulted in a low CLABSI incidence, offering a promising strategy to reduce CLABSIs in a NICU.

Reducing Erythrocyte Sedimentation Rate Ordering: De-implementation and Diagnostic Stewardship.

The Choosing Wisely campaign recommends against the routine use of erythrocyte sedimentation rate (ESR) for the assessment of acute undiagnosed inflammation or infection. We examined ESR and C-reactive protein (CRP) ordering practices at a large, freestanding children's hospital. We found that 80% of ESR orders were placed concurrently with a CRP order. We aimed to reduce the ESR testing rate by 20% within 6 months in both inpatient and emergency department (ED) settings. Applying Lean process improvement principles, we interviewed stakeholders from multiple subspecialties and engaged the institutional laboratory stewardship committee to identify the root causes of ESR ordering and design interventions. We conducted provider education (November 2020) and employed clinical decision support through an order panel in the electronic health record (April 2021). The outcome measures were monthly ESR testing rate per 1000 patient days (inpatient) and per 1000 ED visits, analyzed using statistical process control charts. CRP testing rate was a balancing measure. After intervention implementation, the ESR testing rate decreased from 11.4 to 8.9 tests per 1000 inpatient patient days (22% decrease) and from 49.4 to 29.5 tests per 1000 ED visits (40% decrease). This change has been sustained for >1 year postintervention. Interventions were effective even during the coronavirus disease 2019 pandemic when there was a rise in baseline ED ESR ordering rate. CRP testing rates did not increase after the interventions. Education and clinical decision support were effective in reducing the ESR ordering rate in both inpatient and ED settings.

Prevalence of and Risks for Bacterial Infections in Hospitalized Children With Bronchiolitis.

Viral bronchiolitis is a common pediatric illness. Treatment is supportive; however, some children have concurrent serious bacterial infections (cSBIs) requiring antibiotics. Identifying children with cSBI is challenging and may lead to unnecessary treatment. Improved understanding of the prevalence of and risk factors for cSBI are needed to guide treatment. We sought to determine the prevalence of cSBI and identify factors associated with cSBI in children hospitalized with bronchiolitis. We performed a retrospective cohort study of children <2 years old hospitalized with bronchiolitis at a free-standing children's hospital from 2012 to 2019 identified by International Classification of Diseases codes. cSBI was defined as bacteremia, urinary tract infection, meningitis, or pneumonia. Risk factors for cSBI were identified using logistic regression. We identified 7871 admissions for bronchiolitis. At least 1 cSBI occurred in 4.2% of these admissions; with 3.5% meeting our bacterial pneumonia definition, 0.4% bacteremia, 0.3% urinary tract infection, and 0.02% meningitis. cSBI were more likely to occur in children with invasive mechanical ventilation (odds ratio [OR] 2.53, 95% confidence interval [CI] 1.78-3.63), a C-reactive protein ≥4 mg/dL (OR 2.20, 95% CI 1.47-3.32), a concurrent complex chronic condition (OR 1.67, 95% CI 1.22-2.25) or admission to the PICU (OR 1.46, 95% CI 1.02-2.07). cSBI is uncommon among children hospitalized with bronchiolitis, with pneumonia being the most common cSBI. Invasive mechanical ventilation, elevated C-reactive protein, presence of complex chronic conditions, and PICU admission were associated with an increased risk of cSBI.

Shortening treatment duration for uncomplicated community acquired pneumonia to align with best practice guidelines in a large academic paediatric emergency department

Recommendations for antibiotic therapy for community acquired pneumonia recently changed from 10-day to 5-day duration. This quality improvement project aimed to change the practice of providers in an urban, free-standing children's hospital paediatric emergency department in the United States to match the updated recommendations. Improvement interventions included educational outreach, data sharing, on-site reminders, and audit-and-feedback. The project included analysis of ED return visits to monitor possible treatment failure. Interventions successfully increased 5-day antibiotic prescription rate from 3% to 85% within 12 months.

Caregiver Satisfaction with Medical Providers' Communication: Comparison Between Spanish-Speaking Caregivers with Limited English Proficiency (LEP) and Caregivers Who Are English-Proficient (EP).

Barriers to communication have been observed with patients and families who prefer a language other than English for medical conversations, referred to as individuals with limited English proficiency (LEP). We used the pediatric Family Satisfaction with ICU 24R (FS-ICU) survey to assess communication satisfaction for English-proficient (EP) and Spanish-speaking LEP caregivers. We added additional questions related to attendance at morning rounds, frequency of provider updates, interpreter use, and general satisfaction with communication. This was a single-center, prospective, observational cohort study in the pediatric intensive care unit (PICU) and cardiothoracic intensive care unit (CICU) of a tertiary, academic, free-standing children's hospital. Caregivers of children < 18 years old admitted for at least 48 h to the PICU or CICU between June and September 2022 were eligible for enrollment. 24LEP and 74 EP caregivers completed the survey questions. The LEP group had lower household income and education levels and higher incidence of public insurance. FS-ICU scores for both LEP and EP caregivers suggested high satisfaction, without significant difference between the groups. However, qualitative analysis revealed dissatisfaction for LEP caregivers related to information, inclusion, and language barriers. EP caregivers had more positive references to information and emotional connection but indicated dissatisfaction around consistency and responsiveness. 18%of LEP caregivers reported regularly attending rounds, versus 67% of the EP group (p value < .001). 39% ofLEP versus 52% of EP caregivers reported multiple daily updates, although the difference was not statistically significant. 29% of LEP respondents reported nonfluent MD/NPs using an interpreter never, rarely, or some of the time. There was no difference in satisfaction scores between LEP and EP caregivers. LEP caregivers had lower socioeconomic status based on public insurance and reported income and education level. Qualitative data allowed more nuanced understanding of communication satisfaction, which correlated with LEP caregivers' reported lower attendance at morning rounds, inconsistent interpreter use, and a trend toward less frequent provider updates.

Comparing Outcomes Between Direct and ED Admissions for Neonatal Hyperbilirubinemia.

Pediatric direct admissions (DA) have multiple benefits including reduced emergency department (ED) volumes, greater patient and provider satisfaction, and decreased costs without compromising patient safety. We sought to compare resource utilization and outcomes between patients with a primary diagnosis of neonatal hyperbilirubinemia directly admitted with those admitted from the ED. Single-center, retrospective study at a large, academic, free-standing children's hospital (2017-2021). Patients were between 24 hours and 14 days old with a gestational age of ≥35 weeks, admitted with a primary diagnosis of neonatal hyperbilirubinemia. Outcomes included length of stay (LOS), time to clinical care, resource utilization, NICU transfer, and 7-day readmission for phototherapy. A total of 1098 patients were included, with 276 (25.1%) ED admissions and 822 (74.9%) DAs. DAs experienced a shorter median time to bilirubin level collection (1.9 vs 2.1 hours, P = .003), received less intravenous fluids (8.9% vs 51.4%, P < .001), had less bilirubin levels collected (median of 3.0 vs 4.0, P < .001), received phototherapy sooner (median of 0.8 vs 4.2 hours, P < .001), and had a shorter LOS (median of 21 vs 23 hours, P = .002). One patient who was directly admitted required transfer to the NICU. No differences were observed in the 7-day readmission rates for phototherapy. Directly admitting patients for the management of neonatal hyperbilirubinemia is a preferred alternative to ED admission as our study demonstrated that DAs had a shorter time to clinical care, shorter LOS, and less unnecessary resource utilization with no difference in 7-day readmissions for phototherapy.

Diagnostic Identification of Acute Brain Dysfunction in Pediatric Sepsis and Septic Shock in the Electronic Health Record: A Comparison of Four Definitions in a Reference Dataset.

Acute brain dysfunction (ABD) in pediatric sepsis has a prevalence of 20%, but can be difficult to identify. Our previously validated ABD computational phenotype (CP ABD ) used variables obtained from the electronic health record indicative of clinician concern for acute neurologic or behavioral change. We tested whether the CP ABD has better diagnostic performance to identify confirmed ABD than other definitions using the Glasgow Coma Scale or delirium scores. Diagnostic testing in a curated cohort of pediatric sepsis/septic shock patients. Quaternary freestanding children's hospital. The test dataset comprised 527 children with sepsis/septic shock managed between 2011 and 2021 with a prevalence (pretest probability) of confirmed ABD of 30% (159/527). CP ABD was based on use of neuroimaging, electroencephalogram, and/or administration of new antipsychotic medication. We compared the performance of the CP ABD with three GCS/delirium-based definitions of ABD-Proulx et al, International Pediatric Sepsis Consensus Conference, and Pediatric Organ Dysfunction Information Update Mandate. The posttest probability of identifying ABD was highest in CP ABD (0.84) compared with other definitions. CP ABD also had the highest sensitivity (83%; 95% CI, 76-89%) and specificity (93%; 95% CI, 90-96%). The false discovery rate was lowest in CP ABD (1-in-6) as was the false omission rate (1-in-14). Finally, the prevalence threshold for the definitions varied, with the CP ABD being the definition closest to 20%. In our curated dataset of pediatric sepsis/septic shock, CP ABD had favorable characteristics to identify confirmed ABD compared with GCS/delirium-based definitions. The CP ABD can be used to further study the impact of ABD in studies using large electronic health datasets.