Freestanding Pediatric Hospital Research Articles

Impact of upper airway obstruction management in Robin Sequence on need for myringotomy tubes

ObjectiveInvestigate an association between upper airway obstruction (UAO) management in Robin Sequence (RS) and need for bilateral myringotomy and tubes (BMT). MethodsRetrospective chart review of RS patients treated at a tertiary free-standing pediatric hospital from 1995 to 2020 was performed. Patients were grouped based on airway management: conservative, tracheostomy, tongue-lip adhesion (TLA), and mandibular distraction osteogenesis (MDO). Demographic data, cleft palate (CP) association, numbers of BMT and ear infections, and audiogram data including tympanograms were collected. One-way ANOVA and Chi-square/Fisher's exact tests were used to compare continuous and categorical data, respectively. Multivariable regression analysis was used to compare BMT rates between treatment groups. ResultsOne hundred forty-eight patients were included, 70.3 % of which had CP. Most patients (67.6 %) had at least one BMT; 29.1 % required two or more BMT. The rate of BMT was higher in patients with CP compared to those with intact palates (p = 0.003; 95 % CI 1.30–3.57) and those treated with tracheostomy (p = 0.043; 95 % CI 1.01, 2.27). Surgically managed patients were more likely to have hearing loss (67.5 % vs. 35.3 %, p = 0.017) and ear infections (42.1 % vs. 20.0 %, p = 0.014) pre-compared to post-procedure for airway management. ConclusionMost RS patients require at least 1 set of BMT. Those with CP and/or treated with tracheostomy had a higher likelihood of needing BMT. Rate of hearing loss and ear infection was higher in surgically managed RS patients. Patients with RS and overt CP require a statistically higher number of BMTs compared to those with either submucous cleft palate or intact palate.

Child Protection System Interactions for Children With Positive Urine Screens for Illicit Drugs

Young children are ingesting illicit drugs at increased rates, but it is unknown what the associated child protection system (CPS) responses are when a child tests positive. To document the child protection system involvement and the characteristics of children who test positive for illicit substances. This retrospective cross-sectional study linked medical discharge and child protection system administrative data. The setting was Rady Children's Hospital San Diego, a free-standing pediatric hospital in California. Participants included all emergency department and inpatient medical encounters involving children aged 12 years or younger with a positive urine drug test between 2016 and 2021. Statistical analysis was performed from February 2023 to January 2024. Drug type, including amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, fentanyl, opiates, and phencyclidine. CPS responses associated with the medical encounter including reports, substantiations, case openings, and out-of-home placements. A total of 511 emergency department and inpatient medical encounters involving children had a positive drug test (262 [51.3%] were female; 309 [60.5%] were age 6 years or younger; fewer than 10 [<3.0%] were American Indian or Alaska Native; 252 [49.3%] were Hispanic [any race], 20 [3.9%] were non-Hispanic Asian, 56 [11.0%] were non-Hispanic Black, 143 [28.0%] were non-Hispanic White, 36 [7.0%] had other or unknown race and ethnicity; 233 [43.6%] had a CPS report prior to the medical encounter). Following the positive screen, 244 (47.7%) were reported to child protection, and 61 (11.9%) were placed out-of-home within 30 days. Mean (SD) quarterly counts of encounters with positive drug tests doubled after the COVID-19 pandemic onset (32.9 [9.8]) compared with prior to the pandemic onset (16.5 [4.7]); for encounters positive for cannabis, mean (SD) quarterly counts were 3 times as high after the pandemic onset than prior (16.6 [4.7] vs 5.7 [2.9]). Encounters for children under age 1 were significantly more likely to have associated child protection reports (relative risk [RR], 2.91 [95% CI, 2.21-3.83]) and child protection case openings (RR, 1.71 [95% CI, 1.07-2.72]) than encounters involving older children. In this cross-sectional study of emergency department and inpatient medical encounters, less than half of children with positive urine drug screens were reported to CPS; out-of-home placements were uncommon. With increased encounters for positive drug tests, it is unclear what services these children and families are receiving.

Can Alveolar Bone Grafting Using Posterior Iliac Crest be a Day Surgery Procedure?

The purpose of this study was to determine if patients undergoing alveolar bone grafting (ABG) can be discharged home on the day of surgery safely and with high satisfaction. This is a prospective cohort study of patients who underwent ABG over a 6-month period (August 2022 to February 2023). Medical records were reviewed, and postoperative surveys were provided to assess patient/family experience. Tertiary care free-standing pediatric hospital. Participants who had ABG using iliac marrow from the posterior iliac crest. Subjects were assigned to overnight admission (ON) or day surgery (DS) based on hospital bed capacity. Main outcome measures were postoperative medical events and satisfaction with discharge timing. 41 participants were included: ON, n = 20 (48.8%); DS, n = 21 (51.2%), and there were no differences between groups in any predictor variable. There were no postoperative medical events. Overall, families reported comfort managing pain, nausea, bleeding, hydration, and nutrition after discharge. Most (83.3% of the DS group and 69.2% of the ON group, P = .644) reported satisfaction with the discharge timing they received, despite this being driven by hospital rather than patient factors. Reasons for some families preferring longer admission included fluid management (n = 2), anxiety about postoperative swelling (n = 2), and a long drive home (n = 1). For the ON group, 16.7% would have preferred same-day discharge. Same day discharge is safe and well-received in appropriately selected patients who undergo ABG using posterior iliac crest. Perioperative patient/family education is essential.

Clarification of adverse drug reactions by a pharmacovigilance team results in increased antibiotic re-prescribing at a freestanding United States children's hospital.

Documentation of adverse drug reactions (ADRs) is a key factor in guiding future prescribing. However, incomplete documentation is common and often fails to distinguish implicated drugs as true allergies. This in turn leads to unnecessary avoidance of implicated drug classes and may result in sub-optimal prescribing. Pharmacovigilance (PV) programs utilize a systematic approach to clarify ADR documentation and are known to improve patient safety. Yet it remains unclear if PV alters prescribing. Or, if the existence of the ADR documentation itself continues to prompt avoidance of implicated drugs. To address this, our work presents a retrospective cohort study assessing if clarification of antibiotic ADRs by a hospital-wide PV team was associated with future, safe, re-prescribing at a freestanding pediatric hospital in the midwestern United States. First, we compared the likelihood of future prescribing in an antibiotic class with an active ADR, as compared to alternative drug classes, between PV-clarified and non-clarified patients. Second, we assessed differences in adverse event rates 30-days after future prescribing based on PV clarification status. For robustness, analyses were performed on patients with ADRs in four antibiotic classes: penicillin-based beta-lactams (n = 45,642), sulfonamides/trimethoprim (n = 5,329), macrolides (n = 3,959), and glycopeptides (n = 622). Results illustrate that clarification of an ADR by PV was associated with an increased odds of future prescribing in the same drug class (Odds Ratio [95%-CI]): penicillin-based beta-lactams (1.59 [1.36-1.89]), sulfonamides/trimethoprim (2.29 [0.89-4.91]), macrolides (0.77 [0.33-1.61]), and glycopeptide (1.85 [1.12-3.20]). Notably, patients clarified by PV experienced no increase in the rate of adverse events within 30-days following the prescribing of antibiotics in the same class as an active ADR. Overall, this study provides strong evidence that PV reviews safely increase the rate of re-prescribing antibiotics even in the presence of an existing implicated drug ADR.

Probiotics and Antibiotic-Associated Diarrhea in Pediatric Complicated Appendicitis

Abstract Introduction An appendectomy is the most common urgent surgical intra-abdominal procedure performed on children. Approximately one third of the population ends up having complicated appendicitis requiring the use of intravenous antibiotics and a prolonged hospital stay. Antibiotic-associated diarrhea (AAD) is a common obstacle seen in both outpatient and inpatient settings. Use of probiotics in a pediatric population exposed to antibiotics and gastrointestinal surgery such as an appendectomy may provide a protective effect and prevent AAD. Methods This study was a prospective randomized controlled trial conducted at a large freestanding pediatric hospital. Patients in the treatment group received a standard dose of Lactobacillus rhamnosus GG capsule twice a day until discharge, and those in the control group received a placebo twice a day until discharge. In this study, we hypothesize that patients given probiotics will decrease the overall length of stay (LOS) by 25% versus the LOS in those patients who do not receive probiotics. Results Ninety-eight patients were randomized, with 93 included in the data analysis, into the probiotic group (n = 57) and the placebo group (n = 41). The LOS for the probiotic group (n = 53; M = 121.55, SD = 59.51) was lower than that for the placebo group (n = 40; M = 131.69, SD = 74.27) but was not found to be statistically different (t(91) = 0.731, p = .467). The average total number of diarrhea counts was higher in the probiotic group (M = 13, SD = 16) than in the placebo group (M = 10, SD = 11) but was not found to be statistically different (t(91) = −1.017, p = .312). Discussion Use of probiotics to reduce AAD has been found to be effective in other patient populations. Because of the small sample size, we were unable to determine if the use of L. rhamnosus in patients with complicated appendicitis was effective in reducing the LOS or average diarrhea counts.

Association between preoperative respiratory symptoms and perioperative respiratory adverse events in pediatric patients with positive viral testing

Study objectiveTo determine the association between the presence of upper respiratory tract viral infection symptoms and occurrence of perioperative respiratory adverse events (PRAE) in children with positive viral screening, and to analyze the risk of PRAE in children with SARS-CoV-2 compared to non-SARS-CoV-2 infection. DesignA prospective cohort study. SettingA tertiary, freestanding pediatric hospital in Dallas, Texas. PatientsChildren <18 years of age with positive respiratory viral testing who underwent general anesthesia. InterventionMeasurement of incidence of PRAE and severe adverse events during the first 7 postoperative days. MeasurementsThe primary outcome was a composite of PRAE: oxygen saturation < 90% for >5 min, supplemental oxygen for >2 h after anesthesia, laryngospasm, and bronchospasm. The secondary outcome was severe adverse events: high flow nasal cannula >6 l of oxygen per minute, admission to the ICU for escalation of respiratory support post-anesthetic, acute respiratory distress syndrome, postoperative pneumonia, cardiovascular arrest, extracorporeal life support, and death. Main resultsIn this convenience sample of 196 children, 83 were symptomatic and 113 were asymptomatic. The risk of PRAE was similar in children with active viral symptoms and asymptomatic children (risk difference: −1.9%; 95% CI: −10.9, 7.9%), but higher among children with documented fever within 48 h of the anesthetic (risk difference: 20.8%; 95% CI: 5.3, 39.7%). The multivariable adjusted odds ratio of PRAE was 0.68 (95% CI: 0.25, 1.85) for symptomatic compared to asymptomatic patients, and 0.46 (95% CI: 0.14, 1.44) for patients with SARS-CoV-2 compared to non-SARS-CoV-2 infection. ConclusionsThere was no significant difference in the incidence of PRAE between symptomatic and asymptomatic children with laboratory confirmed viral respiratory infection, and between children with the Omicron variant of SARS-CoV-2 compared to non-SARS-CoV-2 respiratory viruses. However, the risk was increased in children with recent fever.

Individualized Antibiotic Plans as a Quality Improvement Initiative to Reduce Carbapenem Use for Hematopoietic Cell Transplant Patients at a Freestanding Pediatric Hospital.

Providers must balance effective empiric therapy against toxicity risks and collateral damage when selecting antibiotic therapy for patients receiving hematopoietic cell transplant (HCT). Antimicrobial stewardship interventions during HCT are often challenging due to concern for undertreating potential infections. In an effort to decrease unnecessary carbapenem exposure for patients undergoing HCT at our pediatric center, we implemented individualized antibiotic plans (IAPs) to provide recommendations for preengraftment neutropenia prophylaxis, empiric treatment of febrile neutropenia, and empiric treatment for hemodynamic instability. We compared monthly antibiotic days of therapy (DOT) adjusted per 1000 patient-days for carbapenems, antipseudomonal cephalosporins, and all antibiotics during two 3-year periods immediately before and after the implementation of IAPs to measure the impact of IAP on prescribing behavior. Bloodstream infection (BSIs) and Clostridioides difficile (CD) positivity test rates were also compared between cohorts. Last, providers were surveyed to assess their experience of using IAPs in antibiotic decision making. Overall antibiotic use decreased after the implementation of IAPs (monthly reduction of 19.6 DOT/1000 patient-days; P = .004), with carbapenems showing a continuing decline after IAP implementation. BSI and CD positivity rates were unchanged. More than 90% of providers found IAPs to be either extremely or very valuable for their practice. Implementation of IAPs in this high-risk HCT population led to reduction in overall antibiotic use without increase in rate of BSI or CD test positivity. The program was well received by providers.

Establishing a Fetal Center in a Freestanding Pediatric Hospital.

Advances in antenatal imaging have allowed early and accurate diagnosis of many fetal anomalies. This, together with the increasing understanding of the natural history of many fetal diseases, has opened the door to the possibility of offering timely fetal interventions in progressive or life-threatening conditions with the intention of improving perinatal outcomes. These interventions can occur at an adult hospital with obstetrical services (with or without pediatric care) or at a freestanding pediatric hospital. In this article, we provide an overview of the approach to develop a comprehensive fetal care center in a freestanding pediatric hospital. Services included prenatal consultation, advanced diagnostics, innovative fetal therapy, research, and special delivery services. We also review the importance of continuous improvement in achieving this goal.

The safe introduction of robotic surgery in a free-standing children's hospital.

The aim of this study is to report the experience of implementing a pediatric robotic surgery program at a free-standing pediatric teaching hospital. A database was created to prospectively collect perioperative data for all robotic surgeries performed by the pediatric surgery department. The database was queried for all operations completed from October 2015 to December 2021. Descriptive statistics were used to characterize the dataset, using median and interquartile ranges for continuous variables. From October 2015 to December 2021, a total of 249 robotic surgeries were performed in the department of pediatric surgery. Of the 249 cases, 170 (68.3%) were female and 79 (31.7%) were male. Across all patients, there was a median weight (IQR) of 62.65kg (48.2-76.68kg) and a median (IQR) age of 16years (13-18years). The median (IQR) operative time was 104min (79.0-138min). The median console time was 54.0min (33.0-76.0min) and the median docking time was 7min (5-11min). The majority of procedures were performed on the biliary tree (52.6%). In the 249 procedures, there were no technical failures of the robot and only two operations (0.8%) were converted to open procedures and one (0.4%) to laparoscopic. This study highlights the ability to successfully integrate a pediatric robotic surgery program into a free-standing children's hospital with a low conversion rate. Additionally, the program extended across multiple surgical procedures and offered real-time exposure to advanced surgical techniques for current and aspiring pediatric surgery trainees.

Establishment of Nurse Case Manager Role in a Pediatric Orthopedic Team.

Incorporating a nurse case manager (NCM) directly into a pediatric orthopedic department was implemented to address gaps in processes that had previously led to common delays in discharge planning. The orthopedic NCM works within an interdisciplinary team and provides guidance and support for both elective and emergent pediatric admissions. Applying continuous improvement techniques, the NCM role included the review of existing processes and determination of root causes of delays. This article describes some of the unique challenges and new processes included in the NCM role in the pediatric orthopedic setting, several solutions created and implemented to address identified delays, and statistical results of anticipatory discharge planning. An NCM role was initiated in the orthopedic department at a quaternary-level freestanding pediatric hospital. After interdisciplinary planning and implementation, the NCM role was established within the orthopedic department to facilitate timely, efficient, safe, and sustained discharges of patients. Success was realized through decreased denials and decreased number of avoidable inpatient days. Once rapport was established and streamlined work was developed, a retrospective review of length of stay was conducted to compare time periods prior to and after embedding this position. Changes in discharge planning processes positively affected the average length of stay for patients managed by the NCM. Cost savings are found in decreased avoidable inpatient days, decreased number of denials of inpatient medical necessity, and improved progression of care, which resulted in timely transitions and discharges. The effects of a consignment process and web-based ordering of durable medical equipment were also evaluated. Although this process in and of itself did not seem to impact length of stay, it did foster an improvement in team satisfaction around discharge readiness. Pediatric orthopedic service teams benefit from the role of the NCM when there is interdisciplinary involvement and a focus on streamlining processes from preadmission through transition of care. Further study in a concurrent design will shed light on other factors that impact length of stay, such as specific diagnoses and medical complexity. Average length of stay is an effective metric for services with a high percentage of elective admissions but may not be as dependable for teams that do not have prescribed lengths of stay. Study with a specific focus around those factors that impact both team and family satisfaction is also indicated.

Identifying risk factors for pediatric central-line–associated bloodstream infections

Background: Pediatric patients often require central venous catheters (CVCs) for a variety of clinical indications, including medication administration, parenteral nutrition, and venous blood sampling. Patients with CVCs are at risk for central-line–associated bloodstream infections (CLABSI). These hospital-acquired infections are often preventable and may lead to increased morbidity and mortality. Clinicians at a 477-bed, freestanding pediatric academic hospital completed a quality improvement project to identify factors that place pediatric patients at increased risk for CLABSI and to outline strategies aimed at CLABSI reduction for our highest-risk patients. Methods: Project leaders completed a literature review to evaluate current research on the topic and then assembled a project team. The team completed a retrospective analysis and categorization of CLABSI cases and reviewed internal CLABSI root-cause analysis data. The group then completed a case–control analysis to identify risk factors in patients with CVCs who developed CLABSIs, compared to patients with CVCs who did not develop CLABSI. Following this analysis, the team created a CLABSI risk-factor tool for use by bedside nurses. This tool described patients with CLABSI risk factors and outlined best practices for CLABSI prevention. Results: Based upon literature review, root-cause analysis data, and retrospective CLABSI case review over the period from 2017 to 2021, an initial list of 9 potential CLABSI risk factors was compiled. A case–control analysis was performed comparing 97 CLABSI cases with 103 matched controls. Univariate, multivariate, and additional covariate analyses were employed to identify 3 factors placing pediatric patients at increased risk for CLABSI. These included (1) multiple enteral devices (ie, 2 or more devices, including gastrostomy tube, jejunostomy tube, gastrostomy or jejunostomy tube, ostomy, and peritoneal drain); (2) multiple CVC entries (ie, CVC used for medications and venous sampling); and (3) long-term CVC plus parenteral nutrition (CVC in place for &gt;21 days and receiving parenteral nutrition and/or intralipids). Conclusions: Pediatric patients with central venous access are vulnerable to CLABSI, and certain patients may be at increased risk. Frontline clinicians may be able to identify these patients and adopt best practices to prevent infection. A tool for use by bedside nurses can be a useful adjunct to existing CLABSI prevention practices.Disclosures: None

Development of a Physician Assistant Orientation Program in a Pediatric Emergency Department.

The role of physician assistants (PAs) in the care of emergency department (ED) patients has been expanding in recent years. However, little is known about how PAs are prepared to practice in pediatric emergency medicine (PEM), and there is no published literature on how to train PAs in independently managing low-acuity visits in the pediatric emergency department (PED). We created a preorientation, orientation, and postorientation program for PAs who are onboarding in the PED at a large, free-standing pediatric acute care hospital. We implemented an evaluation system that assessed readiness for independent practice based on number and type of patients seen as well as supervising physicians' feedback. On average, PAs took care of 877 patients over the course of their first year of employment at the hospital before achieving readiness for independent practice. Most PAs were deemed ready to see low-acuity patients without direct supervision by PEM attendings during their third or fourth quarter of employment. The successful implementation of a 12-month curriculum and individualized feedback allowed our PED to prepare PAs for independent management of the low-acuity PED patient.

Pediatric Outpatient Noncontrast Brain MRI: A Time-Driven Activity-Based Costing Analysis at Three U.S. Hospitals.

BACKGROUND. MRI utilization and the use of sedation or anesthesia for MRI have increased in children. Emerging alternative payment models (APMs) require a detailed understanding of the health system costs of performing these examinations. OBJECTIVE. The purpose of this study was to use time-driven activity-based costing (TDABC) to assess health system costs for outpatient noncontrast brain MRI examinations across three children's hospitals. METHODS. Direct costs for outpatient noncontrast brain MRI examinations at three academic free-standing pediatric hospitals were calculated using TDABC. Examinations were categorized as sedated MRI (i.e., sedation or anesthesia), nonsedated MRI, or limited MRI. Process maps were created to describe patient workflows based on input from key personnel and direct observation. Time durations for each process activity were determined; time stamps from retrospective EMR review were used when possible. Capacity cost rates were calculated for resource types within three cost categories (labor, equipment, and space); cost was calculated in a fourth category (supplies). Resources were allocated to each activity, and the cost of each process step was determined by multiplying step-specific capacity costs by the time required for each step. The costs of all steps were summed to yield a base-case total examination cost. Sensitivity analysis for sedated MRI was performed using minimum and maximum time duration inputs for each activity to yield minimum and maximum costs by hospital. RESULTS. The mean base-case cost for a sedated brain MRI examination was $842 (range, $775-924 across hospitals), for a nonsedated brain MRI examination was $262 (range, $240-285), and for a limited brain MRI examination was $135 (range, $127-141). For all examination types, the largest cost category as well as the largest source of difference in cost between hospitals was labor. Sensitivity analysis found that the greatest influence on overall cost at each hospital was the duration of the MRI acquisition. CONCLUSION. The health system cost of performing a sedated MRI examination was substantially greater than that of performing a nonsedated MRI examination. However, the cost of each individual examination type did not vary substantially among hospitals. CLINICAL IMPACT. Health systems operating within APMs can use this comparative cost information for purposes of cost reduction efforts and establishment of bundled prices.

Current state and future direction of quality improvement in pediatric neurosurgery: a survey of pediatric neurosurgeons.

Quality improvement (QI) is a methodology used to implement sustainable, meaningful change to improve patient outcomes. Given the complex pathologies observed in pediatric neurosurgery, QI projects could potentially improve patient care. Overall, there is a need to characterize the degree of QI opportunities, training, and initiatives within the field of pediatric neurosurgery. Herein the authors aimed to define the current QI landscape in pediatric neurosurgery. A cross-sectional survey was sent to all members of the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section on Pediatric Neurological Surgery via email. The responses were anonymized. Questions addressed several relatable QI topics including 1) training and participation in QI; 2) QI infrastructure; 3) QI program incentives; and 4) general opinions on the National Surgical Quality Improvement Program (NSQIP) database, various QI topics, and QI productivity. Responses were received from 129 participants (20% response rate). Most respondents practiced in an academic setting (59.8%) and at a free-standing pediatric hospital (65.4%). Participation in QI projects was high (81.7%), but only 23.8% of respondents had formal QI training. Only 36.5% of respondents had institutional requirements for QI work; the majority of those were only required to participate as a project team member. Nearly half of the respondents did not receive incentives or institutional support for QI. The majority agreed ("strongly" and "somewhat") that a QI course would be beneficial (75.5%), that QI projects should be considered for publication in neurosurgery journals (88.1%), and that there is a need for national quality metrics (81.4%). Over 88% have an interest in seeing QI project presentations at the annual Pediatric Joint Section meeting. Only 26.3% believed that the NSQIP was a useful QI guide. Respondents suggested further study of the following QI topics: overall rates of infection and their prevention, hydrocephalus, standardized treatment algorithms for common disorders, team communication, pediatric neurosurgery-specific database, access to care, and interprofessional education. Areas of opportunity include specialty-specific QI education, tactics for obtaining support to build the QI infrastructure, increased visibility of QI work within pediatric neurosurgery, and a review of available registries to provide readily available data relevant to this specialty.

Characteristics of Adult Rapid Response Events in a Freestanding Children's Hospital.

To describe nonhospitalized adult rapid response events (adult RREs) in a freestanding children's hospital and examine the relationship between various demographic and clinical factors with the final patient disposition. We retrospectively reviewed records for nonhospitalized patients ≥18 years of age from events that occurred in a freestanding pediatric hospital between January 2011 through December 2020. We examined the relationship between adult RREs and patient demographic information, medical history, interventions, and patient disposition following an adult RRE. Four hundred twenty-nine events met inclusion criteria for analysis. Most events (69%) occurred in females, 49% of events occurred in family members of patients, and 47% occurred on inpatient floor and ICU areas. The most common presenting complaint was syncope or dizziness (36%). Delivery of bad news or grief response was associated with 14% of adult RREs. Overall, 46% (n = 196) of patients were transferred to the pediatric emergency department (ED). Patients requiring acute intervention or with cardiac or neurologic past medical histories were more likely to be transferred to the pediatric ED. Acute advanced cardiac life support interventions were infrequent but, of the patients taken to the pediatric ED, 1 died, and 3 were admitted to the ICU. Adult RREs are common in freestanding children's hospitals and, although rare, some patients required critical care. Expertise in adult critical care management should be available to the rapid response team and additional training for the pediatric rapid response team in caring for adult nonpatients may be warranted.

Expedited Surgical Care of Appendicitis is Associated With Improved Resource Utilization

IntroductionAppendectomy for acute appendicitis is the most common pediatric intra-abdominal operation. Current literature supports the notion that modest in-hospital, preoperative delays are not associated with greater patient morbidity. However, there is less certainty regarding the role that hour-of-presentation plays in determining the timing of surgery. Thus, we aimed to evaluate how after-hours presentation may relate to the timing of surgery and to assess the outcomes and resource utilization associated with expedited appendectomy compared to nonexpedited. MethodsPatient records for children who underwent an appendectomy at a freestanding pediatric hospital from 2015 to 2019 were reviewed. Business hour presentations were defined as arrival at the emergency department from 7 AM to 6 PM. Primary outcomes were hospital length of stay (LOS), cost derived from the Pediatric Health Information System database, perforation, surgical complications, and 30-day readmissions. ResultsNine hundred forty-two patients underwent appendectomy over the study period. The median time to OR was 2.0 h in the expedited cohort and 9.8 h in the nonexpedited group. Presentation during business hours was associated with 4.4 higher odds (P < 0.001) of expedited workflow. Expedited appendectomies were associated with shorter hospital LOS (11.5 h, P < 0.001), less costly admissions ($1,155, P < 0.001); LOS measured in midnights, perforation and readmission rates were similar between groups. ConclusionsWe found reduced resource utilization associated with expedited appendectomy. Additionally, the demonstrated association between the time of presentation to the emergency department (ED) and the timing of surgery may be utilized to inform staffing and resource deployment decisions. Further research regarding the generalizability and sustainability of an expedited presurgical workflow in pediatric appendectomy is certainly indicated.

A survey of inpatient pediatric rehabilitation practices across the United States1.

Objectives included identifying programs that provide pediatric inpatient rehabilitation services (IPRs) across the United States (US), describing differences in location, admission criteria, available resources, personnel and staffing, and populations served between pediatric rehabilitation programs with the overall goal to evaluate rehabilitation needs in geographical areas with limited access for targeted program development. Online survey emailed to pediatric physiatrists who worked or directed IPRs and completed between December 2018 to March 2019. Fifty respondents completed the survey of the seventy-one distributed. Fifty percent of pediatric inpatient rehabilitation services are within a free-standing pediatric hospital with an average of 14 beds. Twenty-eight programs provide acute services with almost half providing accredited specialized programming. All respondents reported that inpatient rehabilitation treatment teams included pediatric physiatry, nursing, social work, and core therapy disciplines. Although characteristics of pediatric inpatient rehabilitation services vary, similarities exist with respect to team composition, clinical coverage, admission or documentation criteria, and outcome measures. The geographic distribution of pediatric IPRs including available specialty programming reveals resource-limited areas. Results from this study emphasize how practice standards or fiscal limitations impact program structure, resources, and ultimately short- and long-term healthcare outcomes among the population of pediatric rehabilitation patients.

Streamlining surgical trays for common pediatric urology Procedures: A quality improvement initiative

Procedures involving the external genitalia are the most common pediatric urologic operations. Our group identified excess instrumentation for these cases to be a potential cause of operating room (OR) inefficiency at our large, freestanding pediatric hospital. This quality improvement (QI) initiative aimed to streamline surgical instrumentation for the most-performed pediatric urologic procedures at our hospital. Six Sigma DMAIC methodology (Define, Measure, Analyze, Improve, Control) guided this multidisciplinary, iterative QI effort. A stakeholder team utilized data review, direct observations, and multiple in-person discussions to create a new "Groin-Penis Tray" (GPT) to replace a larger tray for the 90 most common pediatric urologic procedures. Suture preference cards and expectations about which sutures would be opened for each case were updated. The primary outcome was estimated yearly cost-avoidance due to reduced sterile processing. Additional outcomes included: instruments opened/case, % cases with complete trays, Mayo stand set-up time, and % cases with unused sutures. Balancing measures included: total median OR time and tray weights. Baseline and post-implementation measures were characterized and compared. A QI professional, 10 pediatric urologists, 2 pediatric urology fellows, and multiple OR and sterile processing staff members participated. The Summary Figurecompares baseline and post-implementation measurements. The number of instruments opened/case decreased from 146 to 65. Annual sterile reprocessing costs decreased by >$51,000. Median Mayo stand set-up time decreased from 7.3 to 3.5min (p<0.001). The number of cases with complete trays increased from 7/20 (35%) to 11/20 (55%, p=0.34). The new GPT is 2.7kg lighter than the prior tray. Median OR time remained stable (baseline: 91min; post-implementation: 102min, p=0.44). The number of cases with suture waste decreased from 78% to 0% immediately post-implementation but increased to 40% one year later. This systematic, iterative QI process spanned the course of ∼2 years, including planning, building, and updating new trays, then assessing longer-term success via the control phase. The new GPT is used for most pediatric urologic procedures at our hospital, and benefits include sterile reprocessing cost savings and ergonomics. Our team gained valuable experience related to assessing QI project scope, determining key stakeholders and roles, and strategies for sustainability that we will apply to future initiatives. Streamlining surgical trays for common pediatric urologic procedures at a large freestanding children's hospital using established QI methodology reduced OR cost by >$51,000/year and Mayo stand set-up times without compromising balancing measures.

Analysis of Universal admission laboratory screening for SARS-CoV-2 asymptomatic infection across a large health system

Background: Admission laboratory screening for asymptomatic COVID-19 has been utilized to mitigate healthcare-associated SARS-CoV-2 transmission. A better understanding of the impact of such testing across a variety of patient populations is needed. Methods: Beginning April 2020, every patient admitted within an academic healthcare system underwent SARS-CoV-2 PCR testing upon admission. Between April 20, 2020 through June 14, 2021, results were analyzed in asymptomatic patients across 4 inpatient facilities: a tertiary-care adult hospital, a free-standing pediatric hospital, a community-based hospital, and a behavioral health hospital. Positivity rates and the number needed to test (NNT) to identify 1 asymptomatic infected patient were calculated overall, by hospital type, by patient vaccination status, and by CDC-defined levels of community transmission. Weekly community incidence rates of COVID-19 for the system’s metropolitan service area (8 central Tennessee counties) were obtained from Tennessee Department of Health records. Weekly COVID-19 incidence rates per 100,000 people were calculated using US Census Bureau data. Using a national survey of hospital epidemiologists, a clinically meaningful NNT was identified (ie, 1 positive patient per 100 patients tested). A crude admission testing cost (covering testing supplies, reagents, and lab personnel costs) was obtained from operational data ($50 per test) to assess testing utility. Results: In total, 51,187 tests were collected during the study period with a positivity rate of 1.8%. No periods of low transmission were observed (Table 1). During high transmission periods, the NNT met the clinically relevant threshold in all populations. In addition, the NNT approached or met the 1:100 threshold for most locations during periods of less transmission, suggesting continued benefit even as infection rates decline. In all transmission periods, the NNT for non–fully vaccinated patients met the clinically meaningful threshold, in contrast to testing of fully vaccinated patients (Table 2). Discussion: Implementing an asymptomatic patient admission testing program can provide clinically relevant value based on the NNT, even during lower periods of transmission and in different patient populations. Limiting admission testing to non–fully vaccinated patients during periods of lower transmission may be a strategy to address cost and resource concerns around this practice. Further investigations into the impact of booster vaccination and newer SARS-CoV-2 variants on admission testing programs are also necessary. Although the impact of such testing on healthcare-associated COVID-19 among patients and healthcare workers could not be clearly determined, these data provide important information as facilities weigh the costs and benefits of such testing.Funding: NoneDisclosures: None

Using Margaret Newman's Health as Expanding Consciousness to Explore Pediatric Nurses' Pattern Recognition Process.

This study explored pattern recognition practices of experienced pediatric nurses caring for children with chronic, complex healthcare needs and their families. Nurses worked in the inpatient settings of two different freestanding pediatric hospitals. Margaret Newman's theory of Health as Expanding Consciousness (1999) was used to explore the pediatric nurses' experiences. During interviews, participants (n = 8) related their stories in caring for these children and their families. Individual interview data were blended to examine themes. Participants described people and events in practice that allowed them to use pattern recognition in the care of children with chronic, complex healthcare needs. Pattern recognition developed in acknowledgement of their past experiences in nursing, as well as with each individual patient and family. Participants had the opportunity to reflect on relationships between their day-to-day practice and their experiences building knowledge and understanding in practice. They considered their abilities to move from skills and tasks to appreciating what each patient and family has taught them about their practice of pattern recognition.