General Pediatric Unit Research Articles

40 Trust, belonging and understanding - The experiences of families who use languages other than English (LOE) that are hospitalized on general paediatric inpatient units

Abstract Background Despite recognition that social determinants are critical to health outcomes, many groups, including those with lower incomes, racial/ethnic minorities, and other historically marginalized populations, continue to experience significant social and structural barriers to care. There is need for research that incorporates patient and stakeholder engagement in developing, testing, and disseminating interventions to improve outcomes for patient populations that have been marginalized in the health system. Patients who use a language(s) other than English (LOE) for healthcare communication are at increased risk for experiencing adverse events and worse health outcomes in healthcare settings, including in paediatric hospitals. Canadian census data indicates 12.7% of Canadians predominantly speak a language other than French or English. This work aims to generate knowledge to improve health outcomes for children and families who speak LOE. Objectives (1) To understand the lived experience of families who speak LOE around the hospitalization of their child and (2) To understand the perspectives of patients and families who speak LOE on how the healthcare system can improve care during hospitalization. Design/Methods The premise of this study is participatory research. We designed a qualitative study involving children hospitalized in the General Paediatric Inpatient Unit at the Hospital for Sick Children. The study includes family caregivers of children age 0 to 18 years who identify as speaking LOE. Children and families could speak any language that we were able to obtain interpreter support for. We excluded patients that spoke a traditional Indigenous language as we noted this work required a separate study in partnership with the Indigenous community. We conducted semi-structured virtual individual interviews with children and families post-discharge with a medical interpreter. An interview guide was developed and transcripts were analyzed using thematic analysis. We took several steps to ensure an effective study design given our goals of participatory research including ensuring patient and family engagement throughout the design process. Results 19 families participated in the interviews and 16 different languages were represented amongst our participant groups. Our study is unique in especially unique in it's ability to recruit and interview individuals with so many different primary languages. Our study provides rich insight into opportunities within the paediatric inpatient setting for quality improvement to address the health disparities experienced by patients and families who use LOE for healthcare communication. Our analysis of the interviews identify several themes that provide insight into the lived experience of patients and families who use LOE for healthcare communication. 1) Inconsistent interpreter use affects communication “in the moment” and the ability to develop an “overall understanding” of the current clinical situation and broader healthcare context. Our participants note a "snowball effect" when interpreters are not consistently utilized. 2) In addition to language, multiple additional social factors contribute to an increased sense of vulnerability and modulates how families “trust” the healthcare system. 3) Despite families expressing positive experiences, they noted that they did not, nor expect to feel like they “belonged” within the healthcare system. It is critical to recognize the complex interplay between many factors surrounding our participants’ identities. Though they use a LOE for healthcare, the intersectional marginalization they experience was thoroughly represented during our conversations Conclusion Our research aimed to take a participatory approach to consider the lived experience of patients and families who use LOE for healthcare communication. This work builds on the current literature on patient and family centered care, experiences of families who speak LOE and participatory community-based research in the paediatric hospital settings. Our study's findings support the development of a research and intervention agenda in Canada to improve health outcomes for patients and families with LOE.

A National Analysis of General Pediatric Inpatient Unit Closures and Openings, 2011-2018.

This paper provides an examination of: (1) the frequency and net rates of change for general pediatric inpatient (GPI) unit closures and openings nationally and by state; (2) how often closures or openings are caused by GPI unit changes only or caused by hospital-level changes; and (3) the relationship between hospital financial status and system ownership and GPI unit closures or openings. This study used the Health Systems and Providers Database (2011-2018) plus 3 data sources on hospital closures. We enumerated GPI unit closures and openings to calculate net rates of change. Multinomial logistic regressions analyzed associations between financial distress, system ownership, and the likelihood of closing or opening a GPI unit, adjusting for hospital characteristics. Across the study period, more GPI units closed th opened for a net closure rate of 2.0% (15.7% [638 of 4069] closures minus 13.7% [558 of 4069] openings). When GPI units closed, 89.0% (568 of 638) did so in a hospital that remained operating. Hospitals with the most financial distress were not more likely to close a GPI unit than those not (odds ratio: 1.01 [95% confidence interval: 0.68-1.50]), but hospitals owned by systems were significantly less likely to close a GPI unit than those not (odds ratio: 0.66 [95% confidence interval: 0.47-0.91]). Overall, more GPI units closed than opened, and closures mostly involved hospitals that otherwise remained operational. A hospital's overall financial distress was not associated with GPI unit closures, whereas being owned by a system was associated with fewer closures.

Evaluation of a Pharmacist-Driven Discharge Medication Reconciliation Service Pilot at a Children’s Hospital

OBJECTIVE The purpose of this study was to evaluate the feasibility of a pharmacist-driven discharge medication reconciliation (DMR) service at our children’s hospital by completing a 2-week pilot on a general pediatrics unit. METHODS This was a prospective study and included patients discharged during pilot hours whose DMR was completed by the pharmacist. The primary outcome was evaluation of time required for a pharmacist to complete the DMR. Secondary outcomes included classification of pharmacist interventions made and their associated cost-avoidance, medication-related problems reported within 14 days of discharge, hospital readmission due to medication problems within 30 days of discharge, and medical resident satisfaction assessed via prepilot and postpilot surveys. RESULTS A total of 67 patients had their DMR completed by a pharmacist during the pilot. The pharmacist spent an average of 30 minutes completing each DMR, although this was variable, as evidenced by an SD of 36.4 minutes. Pharmacists documented 89 total interventions during the study period. The most common intervention types were therapeutic optimization (32.6%) and modification of directions (29.2%). Total estimated cost-avoidance during the study pilot was $84,048.01. For the pilot population, 1 medication-related problem was identified within 14 days of discharge. There were no medication-related readmissions identified. Medical residents reported increased confidence that the DMR was completed accurately and satisfaction with the DMR process during the pilot compared with before the pilot. CONCLUSIONS Implementing a pharmacist discharge medication service requires consideration of ­pharmacist time and salary, which may be offset by cost-avoidance.

True Rate of Allergy among Pediatric Inpatients with Penicillin Allergy Labels (TRIAL).

Penicillin allergy is a common drug allergy diagnosis in pediatric patients; however, upon appropriate allergy testing, many of these patients are found not to have a true allergy. For patients with a reported allergy, alternative antibiotics are prescribed, which are less effective, more toxic, or more expensive. There is a lack of data evaluating allergies in hospitalized children and comparing allergy assessments conducted by pediatric allergists and pharmacists. To estimate the percentage of pediatric patients admitted with reported penicillin allergy who did not have a true penicillin allergy. This single-centre prospective cohort study included inpatients between 6 months and 17 years of age, with a documented penicillin allergy, who were admitted to the general pediatric and oncology units of a tertiary care children's hospital between November 2019 and March 2023. The allergy history, evaluation, and risk categorization were performed by pharmacists. The history was reviewed with the allergist, and the patient was then referred, underwent skin testing, or received oral amoxicillin challenge with monitoring for 1 hour. Thirty patients were included, of whom 29 (97%) had delabelling of their penicillin allergy. Four patients (13%) had delabelling on the basis of history alone, without risk assessment. Twenty-five (83%) of the patients were assessed as having low risk; 24 of these had delabelling following oral challenge, and 1 did not complete the oral challenge because of transfer to another hospital. One patient (3%) was assessed as having moderate risk, with delabelling on the basis of results of skin testing and oral challenge. The pharmacist's and allergist's risk assessments were in agreement in 29 (97%) of the 30 cases. Pediatric patients, including those with oncologic malignancies, are often mislabelled as having a penicillin allergy. Pharmacists are able to accurately determine true allergy risk and delabel penicillin allergies for pediatric patients in the hospital setting.

SNAP: Supportive non-invasive ventilation for acute chest syndrome prevention for hospitalized children with sickle cell disease: Perspectives of patients, parents, and the healthcare team.

Acute chest syndrome (ACS) often develops during hospitalizations for sickle cell disease (SCD) vaso-occlusive episodes and may be triggered by a combination of chest wall splinting, opioid use, hypoventilation, and atelectasis. In 2017, Boston Medical Center's general pediatric inpatient unit instituted the novel use of bi-level positive airway pressure (BiPAP) as "supportive non-invasive ventilation for ACS prevention" (SNAP) to prevent ACS and respiratory decompensation. The goals of this qualitative study were to identify perceived benefits, harms, facilitators, and barriers to use of SNAP. We conducted semi-structured key informant interviews at three sites with different levels of SNAP implementation (Site 1: extensive implementation; Site 2: limited implementation; Site 3: not yet implemented) regarding experiences with and/or perceptions of SNAP. Interviews and coding were guided by the Promoting Action on Research Implementation in Health Services (PARiHS) framework. Thirty-four participants (physicians, nurses, respiratory therapists, child life specialists, psychologists, youth with SCD, and parents) completed interviews. Major themes included: (i) participants perceive BiPAP as effective at preventing ACS, and for those with medically stable ACS, for preventing respiratory decompensation. (ii) BiPAP use is appropriate on the general pediatric inpatient unit for medically stable patients with SCD. (iii) Improving the patient experience is the most important factor to optimize acceptance of BiPAP by patients and families. SNAP is perceived as effective and appropriate for hospitalized pediatric patients with SCD. Improving the patient experience is the biggest challenge. These data will inform a future protocol for a multicenter hybrid effectiveness/implementation trial of SNAP.

Impact of Intravenous Methadone Dosing Schedule on Iatrogenic Withdrawal Syndrome in a Pediatric Intensive Care Unit.

To compare median Sophia Observation withdrawal Symptoms scale (SOS) scores between -intravenous methadone dosing scheduled every 6 hours or every 8 hours for iatrogenic withdrawal -syndrome (IWS). This single-center, retrospective chart review evaluated patients aged 4 weeks through 18 years treated with intravenous methadone for IWS. Children admitted to the pediatric intensive care unit (PICU) of a tertiary care children's hospital between August 2017 and July 2021 and treated for IWS for at least 48 hours were eligible for inclusion. Methadone dosing schedules were compared, with a primary outcome of median Sophia Observation withdrawal Symptoms (SOS) score during the first 24 hours after cessation of continuous fentanyl infusion. Secondary outcomes included PICU and general pediatric unit lengths of stay, extubation failure rates, and mortality. Twenty patients met inclusion criteria, with 9 in the 6-hour dosing group. There was no difference in median SOS score, extubation failure, length of stay, or mortality between the 2 groups. During the first 24 hours after cessation of continuous fentanyl, there appears to be no -difference in IWS severity, as determined by bedside nurse scoring, between patients treated with -intravenous methadone every 6 hours compared with every 8 hours.

PYRIDOXINE-dependent epilepsy (PDE): An observational study of neonatal cases on the role of pyridoxine in patients treated with standard anti-seizure medications

BackgroundThe main objective of this study was to evaluate the neurological consequences of delayed pyridoxine administration in patients diagnosed with Pyridoxin Dependent Epilepsies (PDE). Materials and MethodsWe reviewed 29 articles, comprising 52 genetically diagnosed PDE cases, ensuring data homogeneity. Three additional cases were included from the General Pediatric Operative Unit of San Marco Hospital. Data collection considered factors like age at the first seizure's onset, EEG reports, genetic analyses, and more. Based on the response to first-line antiseizure medications, patients were categorized into four distinct groups. Follow-up evaluations employed various scales to ascertain neurological, cognitive, and psychomotor developments. ResultsOur study includes 55 patients (28 males and 27 females), among whom 15 were excluded for the lack of follow-up data. 21 patients were categorized as "Responder with Relapse", 11 as "Resistant", 6 as "Pyridoxine First Approach", and 2 as "Responders". The neurological outcome revealed 37,5 % with no neurological effects, 37,5 % showed complications in two developmental areas, 15 % in one, and 10 % in all areas.The statistical analysis highlighted a positive correlation between the time elapsed from the administration of pyridoxine after the first seizure and worse neurological outcomes. On the other hand, a significant association was found between an extended latency period (that is, the time that elapsed between the onset of the first seizure and its recurrence) and worse neurological outcomes in patients who received an unfavorable score on the neurological evaluation noted in a subsequent follow-up. ConclusionsThe study highlights the importance of early recognition and intervention in PDE. Existing medical protocols frequently overlook the timely diagnosis of PDE. Immediate administration of pyridoxine, guided by a swift diagnosis in the presence of typical symptoms, might improve long-term neurological outcomes, and further studies should evaluate the outcome of PDE neonates promptly treated with Pyridoxine.

Association between protein intake and muscle wasting in critically ill children: A prospective cohort study.

Survival from pediatric critical illness in high-income countries is high, and the focus now must be on optimizing the recovery of survivors. Muscle mass wasting during critical illness is problematic, so identifying factors that may reduce this is important. Therefore, the aim of this study was to examine the relationship between quadricep muscle mass wasting (assessed by ultrasound), with protein and energy intake during and after pediatric critical illness. A prospective cohort study in a mixed cardiac and general pediatric intensive care unit in England, United Kingdom. Serial ultrasound measurements were undertaken at day 1, 3, 5, 7, and 10. Thirty-four children (median age 6.65 [0.47-57.5] months) were included, and all showed a reduction in quadricep muscle thickness during critical care admission, with a mean muscle wasting of 7.75%. The 11 children followed-up had all recovered their baseline muscle thickness by 3 months after intensive care discharge. This muscle mass wasting was not related to protein (P = 0.53, ρ = 0.019) (95% CI: -0.011 to 0.049) or energy intake (P = 0.138, ρ = 0.375 95% CI: -0.144 to 0.732) by 72 h after admission, nor with severity of illness, highest C-reactive protein, or exposure to intravenous steroids. Children exposed to neuromuscular blocking drugs exhibited 7.2% (95% CI: -0.13% to 14.54%) worse muscle mass wasting, but this was not statistically significant (P = 0.063). Our study did not find any association between protein or energy intake at 72 h and quadricep muscle mass wasting.

Metabolic encephalopathies in children: A pragmatic diagnostic approach based on literature analysis.

Inborn errors of metabolism (IEM) in the general population are rare diseases. However, from the perspective of general pediatrics and pediatric intensive care units (PICUs), they are becoming a significant challenge both diagnostically and therapeutically. Clinically, there is a useful division of IEMs with neurological manifestations into 2 categories: acute and progressive encephalopathies. The extent of individual IEMs in these 2 groups varies, requiring different diagnostic strategies. Despite progress in development of diagnostic tools in IEM, initial diagnosis is made on the basis of basic laboratory tests, neuroradiological findings and metabolic screening. In settings of shortage of diagnostic resources and under time pressure, rational decisions should be made based on available clinical data. The text discusses diagnostic aspects of IEM presenting as metabolic encephalopathies, highlighting their significance in the context of general pediatric care and intensive care units (ICUs), and the challenges associated with diagnosis. It should be noted that the paper does not include a discussion of epileptic encephalopathies of IEM etiology, although some cases of metabolic encephalopathies may also present initially as epileptic encephalopathy.

SNAP: Supportive Non-Invasive Ventilation for ACS Prevention in Hospitalized Children with Sickle Cell Disease: Perceptions of Patients, Caregivers, and the Health Care Team

Background: Acute chest syndrome (ACS), the second most common cause of hospitalization and leading cause of death in children with sickle cell disease (SCD), often develops during a hospitalization for acute SCD in the setting of chest wall splinting, hypoventilation, and atelectasis from pain and opioid use. While incentive spirometry is an important component of ACS prevention and management, additional strategies are needed to prevent atelectasis during sleep. Bi-level positive airway pressure ventilation (BiPAP) provides positive pressure breaths through a mask to support ventilation, and is most commonly used to treat respiratory failure and chronic obstructive sleep apnea,. In 2021, we published our clinical innovation using BiPAP during sleep as supportive care during 53 hospitalizations on the general pediatric inpatient unit for hospitalized children with SCD to prevent ACS and/or to prevent acute respiratory failure among children with mild-moderate ACS. We found that our novel use of BiPAP was safe and feasible on a general pediatric unit; when recommended, it was tolerated in 40/53 (75%) hospitalizations. The goal of the current qualitative study was to identify perceived benefits and harms, and facilitators and barriers to the use and widespread implementation of “supportive non-invasive ventilation for ACS prevention” (SNAP) on a general pediatric inpatient unit. Methods: We conducted semi-structured interviews with key implementation partners at Boston Medical Center (pediatric hospitalists and hematologists; nurses, respiratory therapists, child life specialists, clinical leadership, patients, and parents) about their experiences with and perceptions of SNAP. Interviews and a priori codes for the preliminary codebook were guided by the Promoting Action Research on Implementation in Health Services (PARiHS) framework using the Evidence, Context, and Facilitation constructs. Interviews were transcribed, checked for accuracy, and imported into NVivo 12 for analysis. Transcripts were double coded by three team members who independently coded the initial transcripts. The codebook was refined until consensus was reached. Team members independently reviewed data to identify preliminary themes and subsequently consolidated themes as a group. We were particularly interested in themes regarding benefits, advantages, disadvantages, facilitators, and barriers to individual use and institutional implementation of BiPAP as supportive care. Results: Interviews were completed with 16 participants until thematic saturation was reached, including: 5 physicians, 4 nurses, 1 respiratory therapist, 1 child life specialist, 3 parents, and 2 patients. One physician and one nurse had administrative leadership roles. Major themes included: 1) Participants believed that BiPAP is effective at preventing ACS and - when already present - effective at preventing ACS from getting worse. 2) Despite some initial hesitation, inpatient team members endorsed that use of BiPAP on the general pediatric inpatient unit is appropriate. 3) Improving the patient experience with BiPAP is essential and requires a multi-tiered approach including both physical and social components. 4) Communication among inpatient team members and between staff and patients was critical for BiPAP initiation and success. 5) Nurses were key to the intervention success and required additional support. 6) The size of clinical unit and a “buy-in” culture supported intervention success . See Table 1 for detailed subthemes. Conclusions/Future directions: Members of the health care team, patients, and parents perceive SNAP as effective at preventing ACS and respiratory decompensation, and believe that it is appropriate for use with stable hospitalized children at risk for ACS on a general pediatrics inpatient unit. Features of our inpatient pediatrics unit (small size and collaborative relationships between physicians, staff, and nursing leadership) facilitated successful implementation. Improving the patient experience remains a challenge, and will involve technical issues (mask comfort and pressure) and enhanced communication among health care team members and between staff, patients, and caregivers. We are utilizing these data to develop a protocol for a multicenter hybrid effectiveness/implementation trial of SNAP that incorporates these strategies.

SNAP: Implementation of Supportive Non-Invasive Ventilation for Acute Chest Syndrome Prevention in Adults with Sickle Cell Disease

Introduction Acute chest syndrome (ACS) is the 2 nd most common cause of hospitalization and a major cause of mortality in sickle cell disease (SCD). ACS commonly occurs during a hospitalization for a vaso-occlusive crisis (VOC) when the combination of chest wall pain and intravenous opioids may lead to hypoventilation and atelectasis. Incentive spirometry may prevent ACS by encouraging patients to take deep breaths to reduce atelectasis and improve oxygenation, but requires active participation by an awake patient. Non-invasive bi-level positive airway pressure [BiPAP] provides positive pressure breaths via a mask to improve ventilation and prevent atelectasis during sleep. Hospitalized pediatric SCD patients who were at risk for ACS have used nocturnal BiPAP for ACS prevention on the Boston Medical Center (BMC) general pediatric unit since February 2017. In January 2023, BMC instituted the use of nocturnal BiPAP in hospitalized adult patients with SCD who are at high risk for ACS. Methods This is a prospective observational cohort study to examine the safety, acceptability, and tolerability of BiPAP in high-risk adult patients with SCD hospitalized with a VOC. Criteria for increased ACS risk included: 1) Oxygen saturation < 94% on room air at presentation; 2) History of pulmonary hypertension diagnosed by right heart catheterization; 3) Known obstructive sleep apnea (OSA) not currently treated with positive airway pressure; 4) Prior severe ACS requiring invasive or non-invasive ventilation, high-flow oxygen, and/or exchange transfusion; or 5) History of fat emboli syndrome. Exclusion criteria were: 1) OSA being treated with outpatient positive airway pressure, 2) Surgery within the last 30 days, 3) Direct admission to the intensive care unit (ICU). Manual chart extraction was used to collect patient demographic data, medical history, symptoms, vital signs, chest radiography, laboratory data, indications for BiPAP use, and acceptability and use of BiPAP. Results BiPAP was offered during 38 hospitalizations to 25 individual patients (14 (56%) female) between February and July 2023. The mean age was 35.8 years (SD 10.2); 16 (64%) were HbSS, 8 (32%) HbSC and 1 (4%) HbS-β 0. Nineteen patients (76%) were using >1 SCD-modifying therapy; 16 (64%) reported hydroxyurea use. ACS was present on admission in 7 hospitalizations. Patients agreed to try BiPAP in 22/38 hospitalizations (58%) and BiPAP was used for 1 night in 3 hospitalizations, 2 nights in 3 hospitalizations and more than 2 nights in 7 hospitalizations. In 9/22 hospitalizations, attempts at BiPAP use were unsuccessful. Of the 38 hospitalizations in which BiPAP was offered, 3 patients who did not use BiPAP were transferred to the ICU, 2 for ACS and 1 for ketamine infusion for pain that was refractory to high doses of opioids. Three episodes of ACS developed after admission to the hospital: 2 when BiPAP use had not been attempted and 1 when BiPAP was used for 6 days. Blood transfusions were administered during 7 hospitalizations; 5 of which BiPAP was not used. No deaths occurred during this study period. No adverse events were directly attributable to this novel use of BiPAP for ACS prevention. In the 22 encounters where BiPAP use was attempted, four patients noted difficulties with the continuous airflow and feeling suffocated, one reported lightheadedness. One patient who used BiPAP developed oral pain related to periodontal disease. Conclusion Medically stable, adult hospitalized patients with SCD and VOC were willing to try BiPAP to prevent the development of ACS. In 13/22 (59%) BiPAP was tolerated for >1 one night with no adverse events noted. Future directions include optimizing implementation and studying the efficacy of this intervention.

Inpatient pediatric nursing staff experiences treating psychiatric patients: A mixed methods study.

A gap in the literature exists attempting to understand the impact that the influx of pediatric psychiatric patients has had on inpatient general medicine pediatric nursing staff. A mixed-method research study was conducted among full- and part-time pediatric nurses and nursing assistants working on general pediatric units. Quantitative data was collected via an anonymous survey using the Professional Quality of Life Scale version 5 and Support Appraisal for Work Stressors scale. Surveys were followed by semistructured interviews. Of the 158 staff eligible, 47 (29.7%) participated in the quantitative portion. [Correction added on 29 September 2023, after the first online publication: In the preceding sentence, the participation rate was revised from 23.5% to 29.7% in this version.] Significant differences were found between roles, with nurses experiencing lower levels of compassion satisfaction and higher levels of burnout. Role differences were seen in supervisor support and nonwork support, with nurses reporting less support from both. Supervisor support showed a significant correlational relationship with compassion satisfaction and burnout. Nonwork support showed similar correlations with compassion satisfaction and burnout. Themes that emerged from the interviews were Barriers to Care, Emotional Impact, and "Help Me Help You." Nurses may be at greater risk for compassion fatigue due to perceived inadequate support from leadership, unclear role expectations, and lack of resources.

Hospitalists in Pediatric Oncology/Stem Cell Transplant: Successes and Opportunities.

As hospitalized pediatric patients have grown in number and complexity, and residency structural changes have reduced resident coverage, inpatient care models have changed to include additional providers at the "front line." Hospitalists are increasingly employed in general pediatric units, but in specialized inpatient areas, hospitalist care models are less common. Hospitalist programs in pediatric oncology are few and unique, and thus there are limited data assessing this role. Here we describe the oncology/stem cell transplant hospitalist program at the Children's Hospital of Philadelphia with a survey project to assess the perceptions of physicians in the role. Hospitalists from 2017 to 2019 (n=26) were surveyed to assess nonclinical roles and job satisfaction. With a response rate of 84.6%, all respondents concurred work-life balance, hours, and flexibility are attractive and found the field intellectually stimulating. Most (86.4%) agreed there were significant academic opportunities. The vast majority felt this job was valuable in attaining career and personal goals; 95.5% were happy they accepted this position. As the pediatric oncology/stem cell transplant hospitalist position is a viable, versatile career path providing ample academic opportunities and job satisfaction, the expansion of such a model within our institution and others should be well received.

Surgical repair of neonatal total anomalous pulmonary venous connection: A single institutional experience with 241 cases

ObjectiveChallenges persist in surgery for neonatal total anomalous pulmonary venous connection (neoTAPVC), with the high mortality risk not mitigated over time. MethodsA prospectively collected single-center database containing all neonates with TAPVC undergoing biventricular repair in 2012 to 2020 was retrospectively reviewed. The primary outcome was death or postoperative pulmonary venous obstruction (PPVO). Based on the preoperative admission location in our hospital, patients were classified into those being admitted to cardiac intensive care unit versus neonatal intensive care unit or general pediatric intensive care unit. Access to dedicated presurgical care (DPC) was defined as patients who were preoperatively admitted to the cardiac intensive care unit. ResultsOverall, 241 patients with a median age at surgery of 14 days (interquartile range [IQR], 9-21 days) were included. Anomalous return was supracardiac in 38.6%, cardiac in 26.1%, infracardiac in 28.6%, and mixed in 6.6%. Patients receiving DPC had better survival (96.3% vs 84.3%; P = .0028) and lower incidence of PPVO (15.2% vs 28.6%; P = .011) compared with those without DPC. Patients in the DPC group were less likely to undergo operation within 24 hours on presentation (27.1% vs 40.3%; P = .041), had improved lactate clearance (1.5 [IQR, 1.0-2.2] vs 2.8 [IQR, 1.8-4.1]; P < .001), and had lower incidence of postoperative pulmonary hypertension crisis (2.8% vs 18.7%; P < .001) compared with those in no-DPC group. After matching, no difference in PPVO could be observed in patients undergoing conventional versus sutureless repair (22.6% vs 12.9%; P = .29). ConclusionsAccess to DPC potentially improves outcomes in the neoTAPVC setting; freedom from PPVO were similar using conventional versus sutureless repair.

Cigarette smoke exposure of hospitalised children: Prevalence of smoking in parents or carers and admission practices of health services.

The aim of this study is to understand the exposure to second-hand tobacco smoke in the homes of hospitalised children through: (i) understanding the prevalence of smoking in adults or carers and (ii) examining the health services' approach to identifying parental smoking status. This prospective observational study consisted of two surveys: one administered to parents/carers of hospitalised children and one to health services. The first cross-sectional survey aimed to elicit the proportion of children requiring admission to a regional Victorian general paediatric unit who live with adults who smoke cigarettes. The survey was delivered to participating parents/carers during the standard nursing admission process. The second survey was administered across 15 public health services to determine if identification of parent/carer's smoking status is a routine part of their standard paediatric admission practice. For the parental survey, 453 responses were obtained from 782 consecutive new admissions. Nearly a third (n = 136, 30%) requiring hospital admission were found to be living with at least one parent/carer who identified as a current cigarette smoker. Of the 15 health services surveyed, only four (27%) nursing units reported routinely asking parents/carers about their smoking status as part of their standard admission process. Admission to hospital provides an opportunity to enhance care for children by addressing nicotine dependence within their families. Findings suggest routine recording of smoking status can be improved, to drive smoking cessation and brief intervention conversations with parents and carers of children admitted to hospital.

A Quality Improvement Project to Improve Hospital-to-Home Transitions Using Discharge Televisits.

Resident-led discharge "televisits" can improve the safety of hospital-to-home transitions by increasing completed follow-up and providing patients access to their inpatient providers to troubleshoot issues. This single-center quality improvement study was set in a pediatric unit within an academically affiliated public safety-net hospital. By August 2021, the aim was to use resident-led phone call televisits within 72 hours of discharge to increase completed follow-up from 67% to 85% among patients discharged from the general pediatric unit and compare this to patients scheduled for in person visits. Patients were preferentially scheduled for televisits based on investigator-defined criteria to maximize benefit (eg, prescribed new medications). The process measure was the proportion of televisit slots filled. The balancing measures were 7-day emergency department visits and readmissions. Topics addressed during televisits were categorized to qualitatively assess potential benefits. Three hundred and fifteen (44.5%) patients had televisits, 234 (33.1%) in person visits, and 159 (22.5%) unconfirmed follow-up. The available televisit appointments scheduled were 315 of 434 (72.5%). Completed follow-up was 88.3% for televisits and 63.3% for in person visits, compared with 67% during the baseline period. Completed follow-up was 4.4 (95% confidence interval 2.9 to 6.8) times more likely for televisits compared with in person visits after controlling for confounding variables. Common topics addressed during televisits were test results, medication issues, and appointment issues. Emergency department revisits and readmissions were similar between groups. Resident-led discharge televisits are an innovative way to increase completeness of discharge follow-up.

Hospital-acquired venous thromboembolism during invasive mechanical ventilation in children: a single-center, retrospective cohort study

BackgroundInvasive mechanical ventilation (IMV) has been independently associated with hospital-acquired venous thromboembolism (HA-VTE) among critically ill children, including extremity deep venous thrombosis and pulmonary embolism. ObjectivesWe aimed to characterize the frequency and timing of HA-VTE following IMV exposure. MethodsThis was a single-center, retrospective cohort study including children aged <18 years, hospitalized in a pediatric intensive care unit, undergoing mechanical ventilation for >24 hours from October 2020 through April 2022. Encounters with an existing tracheostomy or receiving treatment for HA-VTE prior to endotracheal intubation were excluded. The primary outcomes characterized clinically-relevant HA-VTE, including timing after intubation, location, and the presence of known hypercoagulability risk factors. Secondary outcomes were IMV exposure magnitude, defined by IMV duration and ventilator parameters (ie, volumetric, barometric, and oxygenation indices). ResultsOf 170 consecutive, eligible encounters, 18 (10.6%) experienced HA-VTE at a median of 4 days (IQR, 1.4-6.4) following endotracheal intubation. Those with HA-VTE had an increased frequency of a prior venous thromboembolism (27.8% vs 8.6%, P = .027). No differences in frequency of other HA-VTE risk factors (ie, acute immobility, hematologic malignancy, sepsis, and COVID-19–related illness), presence of a concurrent central venous catheter, or the magnitude of IMV exposure were noted. ConclusionChildren undergoing IMV experience HA-VTE at markedly higher rates than previously estimated in the general pediatric intensive care unit population after endotracheal intubation. While prospective validation is needed, these findings are an important step toward informing the development of risk-stratified thromboprophylaxis trials in critically ill children.

Diagnostic and predictive value of Respiratory Index of Severity in Children (RISC) scoring system in community-acquired pneumonia: a prospective cross sectional study

BackgroundCommunity-acquired pneumonia (CAP) exhibits high mortality rates among children, accounting for up to 50% in severe cases.Respiratory Index of Severity in Children (RISC) score is a six-predictor standardized means for assessment of the severity of respiratory illness among children. The aim of this study was to validate the RISC score in evaluation of mortality outcome in hospitalized infants diagnosed with CAP.MethodsThis prospective cross-sectional study was conducted on 150 Egyptian children who were diagnosed to have CAP, admitted to the general wards and pediatric intensive care units (PICUs) of Cairo University Children Hospital, Faculty of Medicine, Cairo University from September 2019 to June 2020.ResultsMedian RISC score was significantly higher in non-survivors compared with survivors (p < 0.001). There were significant direct correlations between RISC score and each of respiratory distress grade, C-reactive protein (CRP), PICU admission, mechanical ventilation (MV) and mortality (p < 0.05). The RISC score, assessed within 24 h of admission, had sensitivity of 85.71%, and specificity 89.51% in discriminating infants with CAP who survived from those who died (determined at a cut off > 3). The RISC score was a significant predictor for mortality in infants with CAP (Odds ratio = 5.17, p < 0.001).ConclusionThe RISC score helps in prediction of mortality among children with CAP. Future studies are needed to validate RISC score as a guide for effective management protocol.

Epidemiology and Risk Factor Analysis of Children with Bronchiolitis Admitted to the Intensive Care Unit at a Tertiary Care Center in Saudi Arabia

Bronchiolitis is a leading cause of hospitalization worldwide for children aged ≤2 years. Few studies have compared general ward and pediatric intensive care unit (PICU) admissions, particularly in Saudi Arabia. This retrospective cohort study aimed to compare the demographic and clinical characteristics of children with bronchiolitis admitted to the general ward with those admitted to the PICU. Children (≤6 years) previously diagnosed with bronchiolitis and admitted to the PICU or general ward at a tertiary center in Saudi Arabia between May 2016 and May 2021 were included. Multiplex polymerase chain reaction was used to identify respiratory viruses. Of the 417 patients enrolled, 67 (16.06%) were admitted to the PICU. The PICU group was younger (median, 2 months; interquartile range [IQR], 1-5 months) vs. (6 months; IQR, 2.65-13.25 months). There was a dramatic reduction in bronchiolitis admissions during the COVID-19 pandemic. The most common causative virus was respiratory syncytial virus (RSV) (54.9%). In the multivariate regression analysis, hypoxia, hyperinflation on X-ray, and non-RSV bronchiolitis were independently associated with PICU admission. However, a higher chronological age and cough were protective. Children with Down syndrome, immunodeficiency, or neuromuscular disorders, and intermediate preterm infants (29-33 weeks of gestation) are at a high risk of PICU admission (adjusted odds ratio: 2.4, 7.1, 2.9, and 2.9; p = 0.037, 0.046, 0.033, and 0.029, respectively). Bronchiolitis is still one of the leading causes of PICU admission. Particular attention should be paid to preventive measures, especially in the post-COVID-19 era, targeting high-risk groups.

Home-like care: Collaboration between parents and nurses in everyday situations when children are hospitalized.

When children are hospitalized, parents and nurses need to collaborate. This study aims to investigate how parents and nurses experience collaborating and sharing responsibilities and tasks when providing home-like care for hospitalized children in everyday situations. This qualitative study used a hermeneutic phenomenological approach with observations and interviews and was conducted in a general medical pediatric unit. Twelve parents of eleven hospitalized children between the ages of 1 and 6years with various medical diagnoses and seventeen nurses who cared for those children participated in the study. Parents and nurses collaborated and shared responsibilities and tasks to provide home-like care for hospitalized children in everyday situations by making mealtimes seem familiar, maintaining customary sleeping patterns, adapting washing and dressing routines, and facilitating play and activity. Parents and nurses collaborated to maintain a familiar rhythm in an unfamiliar environment to enhance the children's well-being. The nurses' degree of involvement in the children's everyday situations varied from little to moderate to strong, with parents assuming the main responsibilities. Nurses' involvement in children's everyday situations was variable, depending on the complexity of the situations.