General Pediatric Floor Research Articles

Capitalizing on Implementation Science to Advance Antimicrobial Stewardship and Health Equity in Treating Pediatric UTI’s

Background: Pediatric urinary tract infections represent the most common pediatric infection with increasing gram-negative antibiotic resistance. Overutilization of antimicrobials including third generation cephalosporins are known drivers of this resistance. Antimicrobial stewardship (AS) efforts have recently shown that antibiotic selection may be influenced by patient race. Implementation science (IS) can provide frameworks and strategies to improve antimicrobial utilization and equity. Methods: This was a pre/post study of 2 geographically different children’s hospitals general pediatric floors assessing the impact of a set of implementation strategies developed to improve provider knowledge of best practice antimicrobials (based on local susceptibilities for treatment of UTI’s) and influence uptake of best practice prescribing. IS strategies included provider education, local clinical champion and opinion leader involvement, leadership involvement, local policy changes, and stakeholder co-design of decision support tools (a clinical pathway, a specific ITI antibiogram, and a dynamic order set). No education was provided regarding racial differences in prescribing habits. Outcomes were measured utilizing a portion of the RE-AIM Framework of assessing adoption of “Right” antibiotic, order set adoption, and equitable reach (racial differences in prescribing). Results: Hospital A and B had a first-generation cephalosporin prescription rate of 29.7% (n=441) and 20.6% (n-557) pre implementation and 44.6% (n=84) and 47.5% (n=118) post (p < 0 .001). Both hospitals also saw a significant reduction in third-generation cephalosporins. In Hospital A, APRN’s were more likely to prescribe a first generation cephalosporin (52.4%) than a DO (42.1%) or MD (26.4%) pre-implementation (p=0.004). In Hospital B, APRN’s were less likely to prescribe first generation cephalosporins (5.4%) than a DO (28.9%) or MD (19.4%) pre-implementation (p=0.004). No statistical significance was seen post implementation for antimicrobial selection by provider type for either hospital. Based on race, both hospitals had Black and Other patients receiving more first-generation cephalosporins while white patients were more likely to receive third-generation cephalosporins (p=0.033) pre implementation. No statistical significance was seen post implementation for antimicrobial selection based on race. No improvement was seen in order set utilization. Conclusion: With order set utilization not improving with implementation of new dynamic order set, other strategies such as education, clinical champion and opinion leader involvement, and provision of a local UTI antibiogram were likely contributors to the improvement in best antimicrobial for treatment of UTI’s. Further mixed method research is warranted to improve understanding of the relative performance of our strategies, especially the lack of provider adoption of the novel dynamic order set.Disclosure: Jessica Snowden: Advisory board - Pfizer

Benefits and Process of Providing Peer Support for Pediatric Burn Survivors and Caregivers during Inpatient and Outpatient Phases of Recovery.

The World Health Organization reveals that pediatric burns represent a large portion of burns globally (61). Increases in survival rates have guided clinical and research focus on physical, psychological, and social outcomes. Research on other childhood illnesses has shown the efficacy of social support throughout recovery. In the pediatric burn literature, studies have shown the efficacy of burn camps for promoting positive interactions among survivors, learning coping skills, and facilitating socialization and reintegration. However, few studies have focused on the benefits of peer support for pediatric burn survivors and their caregivers in the inpatient and outpatient phases of recovery. This descriptive paper identifies options for building resilience for pediatric burn survivors through peer support in the inpatient and outpatient phases of recovery. The authors discuss options for providing peer support during the coronavirus disease 2019 pandemic on the pediatric intensive care unit, general pediatric floor, and outpatient setting.

Oral enteral nutrition in the emergency department for children with bronchiolitis hospitalized on high flow nasal cannula

ObjectivesWe assessed whether initiation of oral enteral nutrition in the emergency department (ED) for patients with bronchiolitis hospitalized on humidified high flow nasal cannula (HHFNC) was associated with a shorter hospital length of stay (LOS) without an increase in return ED visits or hospital readmissions. Patients and methodsThis retrospective cohort study included children ≤24 months of age with bronchiolitis hospitalized to the general pediatric floor on HHFNC in two time periods: October 1, 2018 – April 30, 2019, and following implementation of a revised institutional bronchiolitis pathway that encouraged enteral nutrition initiation in the ED, October 1, 2021 – April 30, 2022. The primary outcome of interest was hospital LOS where the exposure was enteral feeding in the ED. ResultsWe included 391 ‘fed’, 114 ‘not fed’ and 304 ‘unknown’ patients. HHFNC treatment time (25 h for ‘fed’ vs. 43 h for ‘not fed’ vs. 35 h for‘unknown’, p = 0.0001) and hospital LOS (39 h for ‘fed’ vs. 56 h for ‘not fed’ vs. 48 h for ‘unknown’, p = 0.0001) was shorter in the ‘fed’ group. There were no significant differences in return ED visits or hospital readmissions. Using our median LOS (45.1 h, inter-quartile range 30.2, 64.4 h) while controlling for age, sex, initial HHFNC flow rate, the respiratory oxygenation (ROX) index, viral etiology, and time period, an adjusted logistic regression analysis demonstrated that patients fed in the ED were 1.8 times more likely to have a hospital LOS of <45 h (aOR 1.88, 95% CI 1.11–3.18, p = 0.019). ConclusionsInitiation of oral enteral nutrition in the ED for patients with bronchiolitis on HHFNC is associated with a shorter hospital LOS without an increase in return ED visits or hospital readmissions. Future prospective studies are needed to develop feeding recommendations for children with bronchiolitis receiving HHFNC support.

Financial outcomes of high-flow nasal cannula use for bronchiolitis on the general pediatric floor.

High-flow nasal cannula (HFNC) is an increasingly common treatment utilized for bronchiolitis on general pediatric hospital floors. This could present a financial burden for hospitals if reimbursement has not accounted for the increased costs associated with increased HFNC use. Pediatric Health Information System and Revenue Management Program data set discharges from 2018 to 2019 were utilized to calculate the ratio of reimbursements to costs as a cost coverage ratio (CCR). The CCR was compared by HFNC use, the severity of illness, and payor type. The CCR was highest at 1.68 for children with high severity and HFNC use but varied greatly by payor. The lowest CCR at 0.77 was seen for children with low severity and public insurance and indicated potential financial losses for these patients. This was lower than low-severity patients on HFNC with private payors (1.68) and high-severity patients on HFNC with public payors (1.18).

Knowledge, Attitudes, and Beliefs of Pediatric Health Care Workers: Understanding the Response to COVID-19.

IntroductionThis research aims to assess knowledge, attitudes, and beliefs of PHCW regarding COVID-19.MethodData collected using an electronic survey sent to pediatric health care workers.ResultsAge was not likely to influence willingness to care for patients with COVID-19. Males were more likely to be willing to care for patients than female. Nurse practitioners were more likely to be willing to care for patients with COVID-19 than physicians. Availability of proper personal protective equipment, COVID-19 knowledge, and training did not influence willingness to care for COVID-19 patients. Healthcare workers with a higher risk of COVID-19-related sickness, and who received most of their COVID-19 information from social media, were less likely to be willing to care for COVID positive patients. As perception of hospital preparedness increased, reluctance to care for COVID-19 positive patients decreased.DiscussionHospital preparedness and social media exposure play a significant role in willingness to care for patients with COVID-19.

4.1 STANDARDIZED ACUTE AGITATION MANAGEMENT ACROSS HOSPITAL SETTINGS

Increasingly more children are presenting with worsening acuity of emotional dysregulation, aggression, and agitation in the emergency department (ED) and across other hospital systems. Timely implementation of consistent behavioral health strategies and standardized pharmacological interventions are essential in successfully responding to acute and severe agitation across the continuum of care. We describe the development of an acute agitation algorithm to standardize management of agitation and aggression in the ED and the general pediatric floor. Multidisciplinary workgroups in 2 separate hospital settings at Lurie Children’s Hospital were created to develop an acute agitation algorithm with the aim of standardizing the early identification of signs and symptoms of agitation, implementing a consistent nonpharmacological and pharmacological treatment response, and utilizing consistent debriefing strategies. We developed resources to screen high-risk special populations, build electronic health record identifiers to recognize at-risk patients, create documentation that drives clinical intervention, and develop systemwide workflows and staff education to ensure consistency of implementation through the continuum of care. Stratification of the severity of agitation was used in the algorithm to match behavioral and pharmacological interventions. We will present outcome measures related to pre- and postimplementation of the ED and pediatric acute agitation algorithm, patient acuity, consistency and timeliness of protocol implementation, psychopharmacological interventions, and documentation. Aggression is a serious problem in child and adolescent psychiatry. Pandemic-related factors have contributed to a significant rise in acuity and severity of behavioral dysregulation across hospital settings. Uniform staff training around mental health, implementation of consistent behavioral health de-escalation strategies, and standardized pharmacological approaches to challenging behaviors improve patient care and staff satisfaction.

Characteristics and risk factors associated with critical illness in pediatric COVID-19

BackgroundWhile much has been reported regarding the clinical course of COVID-19 in children, little is known regarding factors associated with organ dysfunction in pediatric COVID-19. We describe critical illness in pediatric patients with active COVID-19 and identify factors associated with PICU admission and organ dysfunction. This is a retrospective chart review of 77 pediatric patients age 1 day to 21 years admitted to two New York City pediatric hospitals within the Northwell Health system between February 1 and April 24, 2020 with PCR + SARS-CoV-2. Descriptive statistics were used to describe the hospital course and laboratory results and bivariate comparisons were performed on variables to determine differences.ResultsForty-seven patients (61%) were admitted to the general pediatric floor and thirty (39%) to the PICU. The majority (97%, n = 75) survived to discharge, 1.3% (n = 1) remain admitted, and 1.3% (n = 1) died. Common indications for PICU admission included hypoxia (50%), hemodynamic instability (20%), diabetic ketoacidosis (6.7%), mediastinal mass (6.7%), apnea (6.7%), acute chest syndrome in sickle cell disease (6.7%), and cardiac dysfunction (6.7%). Of PICU patients, 46.7% experienced any significant organ dysfunction (pSOFA > = 2) during admission. Patients aged 12 years or greater were more likely to be admitted to a PICU compared to younger patients (p = 0.015). Presence of an underlying comorbidity was not associated with need for PICU admission (p = 0.227) or organ dysfunction (p = 0.87). Initial white blood cell count (WBC), platelet count, and ferritin were not associated with need for PICU admission. Initial C-reactive protein was associated with both need for PICU admission (p = 0.005) and presence of organ dysfunction (p = 0.001). Initial WBC and presenting thrombocytopenia were associated with organ dysfunction (p = 0.034 and p = 0.003, respectively).ConclusionsAge over 12 years and initial CRP were associated with need for PICU admission in COVID-19. Organ dysfunction was associated with elevated admission CRP, elevated WBC, and thrombocytopenia. These factors may be useful in determining risk for critical illness and organ dysfunction in pediatric COVID-19.

A qualitative investigation to identify factors influencing relationship formation between pediatric nurses and pediatric interns

Abstract Background Collaborative relationships between nurses and physicians are fundamental to providing optimal patient care. However, effective communication, building trust and respect, and understanding each other can all be challenges in developing these relationships. Purpose We explore nurse and intern (first year resident) experiences of working together on two general care pediatric floors to more fully understand perceptions of their relationship and identify factors that influence or impede collaborative relationships. Methods Using a semi-structured interview guide, we conducted 3 focus groups; one of nurses (n = 5) and two of second year residents (total n = 6) on two general care pediatric teaching floors at a large academic medical center. Thematic data analysis following the “five stages to qualitative research framework” with three independent coders resulted in six themes. Results Six themes emerged as key factors in the formation of positive relationships between nurses and interns. They included “Roles,” “Trust,” “Communication,” “Respect,” “Relationships,” and “Time.” Both nurses and second year residents reflecting on the intern year identified factors integral to their relationship development. Nurses desire to be valued members of the healthcare team and interns desire to be respected as physicians in training. Both value the importance of effective, in-person communication, desire to be viewed as capable in their roles, appreciate that trust and respect are essential for optimal patient care, and understand that time is needed for these to occur. Conclusions Four shared key factors that lead to positive relationships between nurses and interns must be met for effective collaboration to occur. These include good communication, mutual respect, building trust, and role formation. The establishment of shared factors takes time and may have to be built and rebuilt when they are breeched; determining how to decrease the time for them to be established may enable relationship formation to occur earlier in the intern year.

A Longer Route to the PICU Can Lead to a Longer Stay in the PICU: A Single-Center Retrospective Cohort Study.

Admission to the pediatric ICU versus general pediatric floor for patients is a significant triage decision for emergency department physicians. Escalation of care within 24 hours of hospital admission is considered as a quality metric for pediatric E.R. There exists, however, a lack of data to show that such escalation leads to a poor outcome. A retrospective cohort study was conducted to compare outcomes of patients who required escalation of care within 24 hours of hospital admission to the pediatric ICU (cases) from 01/01 2015 to 02/28 2019 with those who were directly admitted from emergency department to the PICU (controls). A total of 327 cases were compared to 931 controls. Univariate and multivariable regression analysis was done to compare the length of stay and mortality data. Patients who required escalation of care were significantly younger (median age 1.9 years compared to 4.6 years for controls) and had lower severity of illness score (PIM 3). Cases had a much higher proportion of respiratory diagnosis. ICU length of stay, hospital length of stay and the direct cost was significantly higher for cases compared to controls. This difference persisted for all age groups and respiratory diagnosis. The cost of care, however, was only different for 1-5 years and >5 years age groups. The difference in ICU length of stay (Δ11.1%) and hospital length of stay (Δ7.8%) persisted on multivariate regression analysis after controlling for age, sex, PIM3 score, and diagnostic variables. There was no difference in mortality on the univariate or multivariate analysis between the 2 groups. Patients who required escalation of care within 24 hours of hospital admissions have more prolonged ICU and hospital stay and potentially increased cost of care. This measure should be considered while making patient disposition decisions in the emergency department.

Prevalence of Social Risks on Inpatient Screening and Their Impact on Pediatric Care Use.

Screening for social determinants of health in the inpatient setting is uncommon. However, social risk factors documented in billing and electronic medical record data are associated with increased pediatric care use. We sought to describe (1) the epidemiology of social risks and referral acceptance and (2) association between social risks identified through routine inpatient screening and care use. Parents of children ages 0 to 18 admitted to a general pediatric floor at an academic children's hospital completed a psychosocial screening survey from October 2017 to June 2019. The survey covered the following domains: finances, housing, food security, medications, and benefits. Patient characteristics and care use outcomes were abstracted from the electronic medical record and compared by using Pearson's χ2 or the Wilcoxon rank test and logistic regression analyses. Of 374 screened families, 141 (38%) had a positive screen result, of whom 78 (55%) reported >1 need and 64 (45%) accepted a community resource. In bivariate analyses, patients with a positive screen result had higher 30-day readmission (10% vs 5%; P = .05), lower median household income ($62 321 vs $71 460; P < .01), lower parental education (P < .01), public insurance (57% vs 43%; P < .01), lived in a 1-parent household (30 vs 12%; P < .01), and had a complex chronic condition (35% vs 23%; P = .01) compared with those with a negative screen result. There was no difference in care reuse by screening status in adjusted analyses. Social risks are common in the pediatric inpatient setting. Children with medical complexity offer a good target for initial screening efforts.

Improving sleep safety for infants less than one year of age on a general pediatric floor

Background: In 2016, the American Academy of Pediatrics (AAP) published updated safe sleep environment recommendations in order to reduce the risk of all sleep-related infant deaths. Currently, infants admitted to the UMass Memorial Children’s Medical Center are often not placed in safe sleep environments. This modeling of unsafe sleep practices by healthcare providers likely increases the prevalence of unsafe sleep practices at home. This quality improvement project seeks to increase the percentage of admitted infants placed in safe sleep environments in order to decrease the risk of sleep-related …

Improving sleep safety for infants less than one year of age on a general pediatric floor

Improving sleep safety for infants less than one year of age on a general pediatric floor

Trampoline Training Trauma: A Diver's Injury

HISTORY: A 15 year old male presented to the emergency department with back pain after sustaining an injury while practicing a diving routine on the trampoline. He was in forward rotation when he landed awkwardly on his chin and upper chest, sending his back into hyperextension with his legs landing above his head. He felt immediate low back pain and complete loss of sensory and motor function of his legs for about 30 seconds. All sensory and motor function subsequently returned and he was able to ambulate from the trampoline into the home. He denied ongoing sensory or motor deficits in his legs, loss of consciousness, neck pain, urinary or bowel incontinence, or upper extremity weakness. PHYSICAL EXAMINATION: Examination revealed a well appearing male who was able to ambulate slowly but independently with normal gait. He had midline tenderness in the upper lumbar vertebrae. There was normal alignment of the spine without step offs. His strength was 5/5 and reflexes were 2+ in lower extremities. He did not have deficits to touch sensation and did not have saddle anesthesia. DIFFERENTIAL DIAGNOSES: 1. Spinal cord contusion 2. Lumbar vertebral fracture 3. Lumbar sprain 4. Acute spondylolysis or spondylolisthesis 5. Lumbosacral neurapraxia TESTS AND RESULTS: Xray of cervical spine, chest, and pelvis: unremarkable CT cervical spine: unremarkable MRI cervical-thoracic-lumbar: - traumatic injury of the lumbar spine with disruption of the interspinous ligament at the L1-L2 level - small ventral extradural hematoma contained by the posterior longitudinal ligament at L2-L4 MRI lumbar spine, hospital day #2: - decrease in size and cradiocaudal extent of the ventral extradural collection - edema within psoas and paraspinal muscles at L2-L4 FINAL DIAGNOSIS: Extradural hematoma of lumbar spine at L2-L4 Tear of interspinous ligament at L1-L2 TREATMENT AND OUTCOMES: 1. Admission to PICU for close neurologic monitoring with neurosurgery and trauma on consult. He did not report further numbness or tingling in lower extremities 2. Physical therapy 3. Stepped down to general pediatric floor on hospital day #2 4. Discharged on hospital day #3 with lumbar sacral orthosis brace 5. Experienced ongoing headaches for several weeks 6. Back to activity as tolerated, continue to monitor recovery.

Platelet Counts and Outcomes in Acute General Pediatric Patients

Background: Platelets are a component of blood with multiple functions including primary hemostasis, immunity, cancer metastasis, and others. Thrombocytopenia is defined as platelet counts less than 150,000 platelets/μl. There are numerous causes of thrombocytopenia but regardless of cause, multiple studies of thrombocytopenia in infants, children, and adolescents admitted to critical care units (neonatal or pediatric) document significant prognostic value for disease severity. However, there is a paucity of information regarding outcomes in children and adolescents with thrombocytopenia admitted to general pediatric floors. Objective: Better understand the significance of platelet counts and thrombocytopenia in our acute general pediatric patients. Methods: Retrospective study conducted on pediatric patients (infants, children, and adolescents up to 19 years of age) admitted to the general pediatric floors at OSF HealthCare Children's Hospital between July 2010 to July 2018. Patients' demographics, source of admission, primary diagnosis, length of stay, initial platelet count, and transfer to higher levels of care were analyzed. Platelet counts were grouped into mean platelet count +/- 2 SD and &lt;150/nL, 150-450/nL, &gt;450/nL for data analysis. Those previously diagnosed with hematological or oncological diagnoses as well as those directly admitted to the NICU or PICU were excluded. A T-test and multivariate model were used to deem statistical significance. Results: 10,858 charts were included in the study after exclusion criteria were met. Of the patients, 48.2% were female and 51.8% male. The mean age was 4.7 (±5.2) years of age. The majority of our general pediatric admissions came from our emergency department followed by outside hospital transfers and then physician offices. The average length of stay was 3.2 days. The mean platelet count was 332.7/nL with a SD of 127.3. We found significance with regards to transfer to higher levels of care in both the mean platelet count with SD and in the grouped platelet counts. Patients with platelet counts &lt;150/nL were 2.9 times more likely to transfer to higher levels of care than those with counts between 150-450/nL (p&lt;.0001, 95% CI 2-4.3) and 2.2 times likely to transfer than those with counts &gt;450/nL (p&lt;.0006, 95% CI 1.4-3.4). Interestingly, we also discovered that outside hospital transfers were more likely to transfer to higher levels of care compared to other sources of admission. Lastly, our top 5 diagnosis categories included: Infection, GI, Kidney/Bladder/Urinary, Neurology, and Muscle Skeletal/Joint. Conclusion: Previous studies done in the NICU and PICU show that thrombocytopenia is associated with poorer outcomes. Our study suggests that this also holds true in the acute general pediatric patient population. Additionally it gives us insight into common diagnosis categories and admission sources which may have more negative outcomes. Our data supports the concept that providers should be aware of the potential negative impact of thrombocytopenia in the acute pediatric patient and pay them closer attention. Disclosures No relevant conflicts of interest to declare.

Pediatric asthma severity scores distinguish suitable inpatient level of care for children admitted for status asthmaticus

Objective: To determine if the Pediatric Asthma Severity Score (PASS) can distinguish “late-rescues” (transfer to the pediatric intensive care unit [PICU] within 24-hours of general pediatric floor admission), “PICU readmissions” (readmission within 24-h after transfer to a lower inpatient level of care), and unplanned 30-day hospital readmission in children admitted with status asthmaticus.Methods: We performed a single center, retrospective cohort study in 328 children admitted for asthma exacerbation aged 5–18 years from May 2015 to October 2017. We sought to determine if PASS values preceding admission from the emergency department or transfer to the general pediatric unit will be greater in children with late rescues and PICU readmissions and if a cutoff PASS values exist to discriminate these events prior to intrafacility transfer.Results: Nine (5%) late-rescues and 5 (3%) PICU readmissions accounted for 14/328 (4%) composite outcomes. PASS values were greater in children with these events (8 [IQR:5–8] vs. 5 [IQR:3–6], p < .01). Logistic regression of PASS on composite outcome yielded an odds ratio of 1.4 (1.1–1.8, p < .01) and ROC curve of PASS on a composite outcome yielded an AUC of 0.74 (0.61–0.87) with a threshold of ≥ 9. Nine (3%) children experienced unplanned 30-day hospital readmissions but PASS preceding hospital discharge was neither discriminative nor associated with hospital readmission.Conclusions: PASS values ≥ 9 identify children at increased risk for late-rescue and PICU readmission. Applied with traditionally criteria for selection of inpatient level of care, PASS may assist providers in reducing acute inpatient disposition errors.

Implementation of a General Pediatric Clinical Rounding Checklist.

Checklists have been found to improve patient outcomes in a variety of health care settings, but use is rare during general pediatric rounds. We aimed to decrease length of stay (LOS) by 10% within 12 months through the standardized delivery of 8 aspects of hospital care for the general pediatric unit. For the general pediatrics unit at our freestanding children's hospital, a clinical rounding checklist was developed through a consensus of teaching faculty. Iterative plan-do-study-act cycles were conducted in a targeted medical unit over a 12-month period. We assessed change using control charts. Checklist use increased from 61% to 96% early in the implementation phase. LOS (72 hours) was relatively unchanged. Cardiorespiratory monitor (CRM) duration was reduced by 28% (17.3 hours) within 4 months and was sustained for more than 12 months. A similar CRM reduction of 29% (22.5 hours) was seen in our medically complex patient subgroup. No clinically significant change was appreciated in central line, peripheral intravenous (IV) catheter, IV fluid, or IV medication duration. Thirty-day readmissions, code blue events, and rapid response team activations were not impacted. The use of a clinical rounding checklist on the general pediatric floor improved care in only 1 of 8 targeted domains. LOS did not change significantly over the project's duration. CRM duration was significantly reduced in both routine patients and medically complex children, and these improvements were sustained without impacting patient safety. More study is needed to determine which checklist components, if any, may prove beneficial to patient outcomes.

Retrospective Review of Limitations of Care for Inpatients at a Free-Standing, Tertiary Care Children's Hospital.

Limited studies exist regarding the timing, location, or physicians involved in do-not-resuscitate (DNR) order placement in pediatrics. Prior pediatric studies have noted great variations in practice during end-of-life (EOL) care. This study aims to analyze the timing, location, physician specialties, and demographic factors influencing EOL care in pediatrics. We examined the time preceding and following the implementation of a pediatric palliative care team (PCT) via a 5-year, retrospective chart review of all deceased patients previously admitted to inpatient services. Thirty-five percent (167/471) of the patients in our study died with a DNR order in place. Sixty-two percent of patients died in an ICU following DNR order placement. A difference was noted in DNR order timing between patients on general inpatient units and those discharged to home compared with those in the ICUs (p = 0.02). The overall DNR order rate increased following the initiation of the PCT from 30.8% to 39.2% (p = 0.05), but no change was noted in the rate of death in the ICUs. Our study demonstrates a variation in the timing of death following DNR order placement when comparing ICUs and general pediatric floors. Following the initiation of the PCT, we saw increased DNR frequency but no change in the interval between a DNR order and death.

Pleth Variability Index to Assess Course of Illness in Children with Asthma

BackgroundStatus asthmaticus (SA) is a common reason for admission to the pediatric emergency department (ED). Assessing asthma severity efficiently in the ED can be challenging for clinicians. Adjunctive tools for the clinician have demonstrated inconsistent results. Studies have shown that pulsus paradoxus (PP) correlates with asthma severity. Pleth Variability Index (PVI) is a surrogate measure of PP. ObjectiveWe investigated whether PVI at triage correlates with disposition from the ED. MethodsWe recruited children aged 2–18 years old who presented to the pediatric ED of a tertiary care children's hospital with SA. PVI, Respiratory Severity Score, and vital signs were documented at triage and 2 hours into each patient's ED stay. PVI was measured using the Masimo Radical-7® monitor (Masimo Corp., Irvine, CA). ResultsThirty-eight patients were recruited. Twenty-seven patients were discharged home, 10 patients were admitted to the general pediatrics floor and 1 patient was admitted to the intensive care unit. PVI values at triage did not correlate with disposition from the ED (p = 0.63). Additionally, when trending the change in PVI after 2 hours of therapy in the ED, no statistically significant patterns were demonstrated. ConclusionsOur study did not demonstrate a correlation between PVI and clinical course for asthmatics. PVI may be more clinically relevant in sicker children. Furthermore, it is possible that continuous monitoring of PVI may demonstrate more unique trends in relation to asthma severity versus single values of PVI. Additional studies are necessary to help clarify the relationship between PVI and the clinical course of children with SA.

Positive Change in Feedback Perceptions and Behavior: A 10-Year Follow-up Study.

Providing and learning from feedback are essential components of medical education, and typically described as resistant to change. But given a decade of change in the clinical context in which feedback occurs, the authors asked if, and how, perceptions of feedback and feedback behaviors might have changed in response to contextual affordances. In 2017, the authors conducted a follow-up, ethnographic study on 2 general pediatric floors at the same children's hospital where another ethnographic study on a general pediatric floor was conducted in 2007. Data sources included (1) 21 and 34 hours of observation in 2007 and 2017, respectively, (2) 35 and 25 interviews with general pediatric attending physicians and residents in 2007 and 2017, respectively, and (3) a review of 120 program documents spanning 2007 to 2017. Data were coded and organized around 3 recommendations for feedback that were derived from 2007 data and served as standards for assessing change in 2017. Data revealed progress in achieving each recommendation. Compared with 2007, participants in 2017 more clearly distinguished between feedback and evaluation; residents were more aware of in-the-moment feedback, and they had shifted their orientation from evaluation and grades to feedback and learning. Explanations for progress in achieving recommendations, which were derived from the data, pointed to institutional and national influences, namely, the pediatric milestones. On the basis of follow-up, ethnographic data, changes in the clinical context of pediatric education may afford positive change in perceptions of feedback and feedback behavior and point to influences within and beyond the institution.

Receiving Providers' Perceptions on Information Transmission During Interfacility Transfers to General Pediatric Floors.

Pediatric patients can present to a medical facility and subsequently be transferred to a different hospital for definitive care. Interfacility transfers require a provider handoff across facilities, posing risks that may affect patient outcomes. The goal of this study was to describe the thoroughness of information transmission between providers during interfacility transfers, to describe perceived errors in care at the posttransfer facility, and to identify potential associations between thoroughness of information transmission and perceived errors in care. We performed an exploratory prospective cohort study on communication practices and patient outcomes during interfacility transfers to general pediatric floors. Data were collected from provider surveys and chart review. Descriptive statistics were used to summarize survey responses. Logistic regression was used to analyze the association of communication deficits with odds of having a perceived error in care. A total of 633 patient transfers were reviewed; 218 transport command physician surveys and 217 frontline provider surveys were completed. Transport command physicians reported higher proportions of key elements being included in the verbal handoff compared with frontline providers. The written key element transmitted with the lowest frequency was a summary document (65.2%), and 13% of transfers had at least 1 perceived error in care. Transfers with many deficits were associated with higher odds of having a perceived error in care. Information transmission during pediatric transfers is perceived to be inconsistently complete. Deficits in the verbal and written information transmission are associated with odds of having a perceived error in care.