Large Urban Pediatric Hospital Research Articles

Development of an Institution-Wide Pediatric End-of-Life Summit.

End-of-life (EOL) care in pediatrics is a unique subspecialty lacking adequate provider education and training. Patient and family outcomes may improve when clinicians are provided with training in this care. Recognizing the need for this specialized education, a small group of bereavement coordinators created an institution-wide pediatric EOL summit at a large urban pediatric teaching hospital. One hundred forty-five clinicians from 14 diverse disciplines attended the first annual pediatric EOL summit. A survey was sent to the participants for feedback. The survey results suggested an overwhelmingly positive response to the summit. Continuing to provide this educational conference is critical to improving care for patients and families, particularly at the end of life.

Implementation of After-Hours Nurse Line in an Academic Pediatric Endocrinology Practice

Background. After-hours triage of pediatric patients by trained nurses improves consistency of triage decisions, access, and quality of care, and decreases burden on physicians on-call. There is a lack of published experience with this approach in the pediatric diabetes population. Methods. An after-hours call service was established in September 2019 in our large urban pediatric teaching hospital. Barton Schmitt guidelines, which are widely accepted as the standard for telephone triage care, were modified to include institution specific diabetes management protocols. We analyzed demographics, reasons for call, clinical presentation to the emergency room, and clinical disposition of the callers. Results. The after-hours call service handled 70% of calls without physician involvement. There were no patients triaged to home care who subsequently required an emergency room visit or hospitalization. Patients who called the after-hours nurse line prior to coming to the emergency room were less sick and were discharged more often from the emergency room. Spanish-speaking parents utilized the service less than English speakers. There were no disparities in utilization based on the insurance status or race. Conclusions. The after-hours service accurately triaged calls and reduced physician burden. Patients of all races and insurance statuses utilized the after-hours service equally well. Language was a barrier in the utilization.

Indicators of Neighborhood-Level Socioeconomic Position and Pediatric Critical Illness

With recent prioritization of equity in pediatric health outcomes, a shift to examine neighborhood-level health care disparities within pediatric populations has occurred, specifically in the context of critical illness. Does an association exist between individual indicators of neighborhood-level disadvantage and incidence of PICU admission? Pediatric patients younger than 18 years admitted to a PICU in a large urban tertiary pediatric hospital from January 1, 2016, through December 31, 2019, with a residential address in the city of Baltimore or Baltimore County on the day of admission were included in this ecological study. Demographic and clinical characteristics of children admitted to the PICU were summarized, with the primary outcome being PICU admission. Unadjusted negative binomial regression was used to examine the association between census tract-level PICU admissions and the previously described census tract-level indicators of neighborhood socioeconomic position. Regression models included an offset term for the population younger than 18 years for each census tract; results of models are reported as incidence rate ratios (IRRs) with corresponding 95%CIs. We identified 2,476 PICU admissions: 1,351 patients from the city of Baltimore (10.25 per 1,000 children) and 1,125 patients from Baltimore County (6.31 per 1,000 children). Most PICU admissions (n= 906 [68%]) for the city of Baltimore represented an area deprivation index (ADI) of > 60, whereas most Baltimore County PICU admissions (n= 919 [82.3%]) represented an ADI of< 60. At the neighborhood level, the percentage of families living below the poverty line was associated with greater incidence of PICU admission in the city of Baltimore (IRR, 1.09; 95%CI, 1.00-1.18) and Baltimore County (IRR, 1.19; 95%CI, 1.05-1.36). For every $10,000 increase in median household income, PICU admission rates dropped by 9%for the city of Baltimore (IRR, 0.91; 95%CI, 0.86-0.95) and Baltimore County (IRR, 0.91; 95%CI, 0.88-0.94). Neighborhoods with vacant housing units also were associated with a higher incidence of PICU admission in the city of Baltimore (IRR, 1.10; 95%CI, 1.01-1.21) and Baltimore County (IRR, 1.46; 95%CI, 1.21-1.77), as was a 10%increase in occupied homes without vehicles (city of Baltimore: IRR, 1.14; 95%CI, 1.07-1.21; Baltimore County: IRR, 1.23; 95%CI, 1.11-1.37). Health outcomes of pediatric critical illness should be examined in the context of structural determinants of health, including neighborhood-level and environmental characteristics.

1018-P: Disparities in Diabetes Technology Use in Youth with Diabetes

Background: Diabetes technology can improve glycemic control and diabetes outcomes, but there are disparities in patient use. Aims: Identify racial, ethnic, and socioeconomic disparities in technology utilization and determine provider, patient, and parent identified barriers to this. Methods: Technology (continuous glucose monitors [CGM] and pump) usage and demographic data on patients at a large urban pediatric hospital were obtained from a clinical database. Providers (physicians, nurse practitioners, diabetes educators [CDEs]) completed a survey on diabetes technology prescribing habits. English and Spanish speaking patients ages 8 to 17 years with type 1 or type 2 diabetes on insulin and their guardians completed patient and parent specific surveys that assessed attitudes and perceived benefits and burdens of diabetes technology. Responses (16 physicians, 11 CDEs, 109 patients, 117 parents) were analyzed with Kruskal-Wallis tests. Results: From August 2020-2021, independent of socioeconomic status, non-Hispanic Black (NHB) and Hispanic children were less likely to be prescribed pump (odds ratio 0.40 and 0.35 respectively) or CGM (0.50 and 0.49) compared to non-Hispanic White (NHW) children. For pump eligibility, CDEs placed higher importance on subjective factors such as parental education, health literacy, and psycho-social stability (p value &amp;lt; 0.05) compared to physicians. Hispanic and NHB patients and parents learned about diabetes technology later after diagnosis compared to NHW group. Physicians and CDEs identified patient perceived barriers to CGM use (i.e., embarrassment and/or discomfort in wearing devices) as reasons for not discussing technology, though patients did not identify such factors as barriers. Conclusions: There are marked disparities in diabetes technology use among youth with diabetes. Families and providers perceive different barriers to utilization. This study adds perspective of patients with T2D as well as targeted recruitment of underrepresented minorities. Disclosure P.Singh: None. E.Grishman: None. D.Naranjo: None. L.S.Hynan: None. P.C.White: Consultant; Provention Bio, Inc. O.Gupta: None.

Perspectives of Youths on the Ethical Use of Artificial Intelligence in Health Care Research and Clinical Care

Understanding the views and values of patients is of substantial importance to developing the ethical parameters of artificial intelligence (AI) use in medicine. Thus far, there is limited study on the views of children and youths. Their perspectives contribute meaningfully to the integration of AI in medicine. To explore the moral attitudes and views of children and youths regarding research and clinical care involving health AI at the point of care. This qualitative study recruited participants younger than 18 years during a 1-year period (October 2021 to March 2022) at a large urban pediatric hospital. A total of 44 individuals who were receiving or had previously received care at a hospital or rehabilitation clinic contacted the research team, but 15 were found to be ineligible. Of the 29 who consented to participate, 1 was lost to follow-up, resulting in 28 participants who completed the interview. Participants were interviewed using vignettes on 3 main themes: (1) health data research, (2) clinical AI trials, and (3) clinical use of AI. Thematic description of values surrounding health data research, interventional AI research, and clinical use of AI. The 28 participants included 6 children (ages, 10-12 years) and 22 youths (ages, 13-17 years) (16 female, 10 male, and 3 trans/nonbinary/gender diverse). Mean (SD) age was 15 (2) years. Participants were highly engaged and quite knowledgeable about AI. They expressed a positive view of research intended to help others and had strong feelings about the uses of their health data for AI. Participants expressed appreciation for the vulnerability of potential participants in interventional AI trials and reinforced the importance of respect for their preferences regardless of their decisional capacity. A strong theme for the prospective use of clinical AI was the desire to maintain bedside interaction between the patient and their physician. In this study, children and youths reported generally positive views of AI, expressing strong interest and advocacy for their involvement in AI research and inclusion of their voices for shared decision-making with AI in clinical care. These findings suggest the need for more engagement of children and youths in health care AI research and integration.

Virtual Clinics for Diabetes Care.

Virtual Clinics for Diabetes Care.

“We Are Not Taking a Backseat”: Health Social Workers’ Perspectives on COVID-19 Response and Recovery

The COVID-19 pandemic has wrought widespread devastation across the United States, exacerbating existing health inequities rooted in the social determinants of health. Social work is the key workforce tasked with providing social care in healthcare settings. In September 2019, the National Academies of Science, Engineering, and Medicine released a landmark Consensus Study Report, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. The report describes a framework for addressing key care needs that articulates five "As for action" (5As)-awareness, alignment, assistance, adjustment, and advocacy-that are critical to social care. Drawing from a series of focus groups conducted with 55 social workers employed in a large urban pediatric quaternary hospital, this study qualitatively examines the utility of this framework in characterizing social care activities during the pandemic response and recovery efforts. Findings suggest that the 5As framework is both applicable to pandemic social work practice and an accurate encapsulation of the core elements of hospital social work practice, even if social workers themselves may not necessarily be aware of that conceptualization. Future implications for social work practice in arenas of awareness, adjustment, assistance, alignment, and advocacy are also discussed.

A comparative analysis of pediatric mental health-related emergency department utilization in Montréal, Canada, before and during the COVID-19 pandemic

BackgroundReports on longitudinal trends in mental health-related (MHR) emergency department (ED) utilization spanning the pre- and post-pandemic periods are lacking, along with evidence comparing healthcare services utilization by sociodemographic subgroups. The aim of this study was to evaluate COVID-19-associated changes in MHR ED utilization among youth overall and by age, sex, and socio-economic status (SES).MethodsThis retrospective cross-sectional study analyzed MHR ED utilization before and during the COVID-19 pandemic at a large urban pediatric tertiary care hospital in Montréal, Canada. All ED visits for children (5–11 years) and adolescents (12–17 years) between April 1, 2016 and November 30, 2021 were included. The main outcome was the monthly count of MHR ED visits. Pre-pandemic and pandemic periods were compared using an interrupted time series design. The effect of seasonality (in months), age (in years), sex (male or female), and SES (low, average, high) were compared using a generalized additive model.ResultsThere were a total of 437,147 ED visits (204,215 unique patients) during the 5-year study period of which 9748 (5.8%) were MHR visits (7,686 unique patients). We observed an increase of 69% (95% CI, + 53% to + 85%; p = 0.001) in the mean monthly count of MHR ED visits during the pandemic period, which remained significant after adjusting for seasonality (44% increase, 95% CI, + 38% to + 51%; p = 0.001). The chance of presenting for a MHR ED visit increased non-linearly with age. There were increased odds of presenting for a MHR ED visit among girls between the pre-pandemic and pandemic periods (OR 1.42, 95% CI 1.29–1.56). No difference by SES group during and before the COVID-19 pandemic was found [OR 1.01, 95% CI 0.89–1.15 (low); OR 1.09, 95% CI 0.96–1.25 (high)].ConclusionsOur study shows important increases in MHR ED utilization among youth, and especially among girls, during the first 20 months of the COVID-19 pandemic, highlighting the need for sustained, targeted and scalable mental health resources to support youth mental health during the current and future crises.

Physician role differentiation: Patients, practice patterns, and performance.

Multispecialty clinical settings are increasingly prevalent because of the growing complexity in health care, revealing challenges with overlaps in expertise. We study hospitalists and inpatient specialists to gain insights on how physicians with shared expertise may differentiate themselves in practice. The aim of this study was to explore how hospitalists differentiate themselves from other inpatient physicians when treating patient cases in areas of shared expertise, focusing on differences in patient populations, practice patterns, and performance on cost and quality metrics. We use mixed-effects multilevel models and mediation models to analyze medical records and disaggregated billing data for admissions to a large urban pediatric hospital from January 1, 2009, to August 31, 2015. In areas of shared physician expertise, patients with more ambiguous diagnoses and multiple chronic conditions are more likely to be assigned to a hospitalist. Controlling for differences in patient populations, hospitalists order laboratory tests and medications at lower rates than specialists. Hospitalists' laboratory testing rate had a significant mediating role in their lower total charges and lower odds of their patients experiencing any nonsurgical adverse events compared to specialists, though hospitalists did not differ from specialists in 30- and 90-day readmission rates. Physicians with shared expertise, such as hospitalists and inpatient specialists, differentiate their roles through assignment to ambiguous diagnoses and multisystem conditions, and practice patterns such as laboratory and medication orders. Such differentiation can improve care coordination and establish professional identity when roles overlap.

Impact of the COVID-19 pandemic on management of children and adolescents with Type 1 diabetes

BackgroundThe coronavirus disease-2019 (COVID-19) pandemic had widespread impacts on the lives of parents and children. We determined how the pandemic affected Type 1 diabetes patients at a large urban pediatric teaching hospital.MethodsWe compared patient characteristics, glycemic control, PHQ-9 depression screen, in person and virtual outpatient encounters, hospitalizations and continuous glucose monitor (CGM) utilization in approximately 1600 patients in 1 year periods preceding and following the local imposition of COVID-related restrictions on 3/15/2020 (“2019” and “2020” groups, respectively).ResultsIn a generalized linear model, increasing age, non-commercial insurance, Black and Hispanic race/ethnicity, and non-utilization of CGMs were all associated with higher hemoglobin A1c (HbA1c), but there was no difference between the 2019 and 2020 groups. The time in range in CGM users was lower with non-commercial insurance and in Black and Hispanic patients; it improved slightly from 2019 to 2020. CGM utilization by patients with non-commercial insurance (93% of such patients were in government programs, 7% uninsured or “other”) increased markedly. In 2020, patients with commercial insurance (i.e., private-pay or provided by an employer) had fewer office visits, but insurance status did not influence utilization of the virtual visit platform. There was no change in hospitalization frequency from 2019 to 2020 in either commercially or non-commercially insured patients, but patients with non-commercial insurance were hospitalized at markedly higher frequencies in both years. PHQ-9 scores were unchanged.ConclusionsHospitalization frequency, glycemic control and depression screening were unchanged in our large urban pediatric teaching hospital during the COVID pandemic. Increased utilization of CGM and rapid adoption of telemedicine may have ameliorated the impact of the pandemic on disease management.

Engaging End-Users in Electronic Health Record (EHR) Updates: Social Workers’ Opinions on Integrating a Psychosocial Acuity Scale at a Large Urban Pediatric Hospital

The objective of this study was to examine end-user opinions on electronic health record (EHR) modifications related to social work documentation of psychosocial acuity and provision of social care. Content analysis was used to examine end-user opinions (n = 42; 20% of a social work department employed in a large, urban, pediatric hospital) about whether or not to integrate a metric of psychosocial acuity into the EHR and required documentation practices. Most (79%) participants were in favor of EHR integration. Content analysis revealed nine themes in favor and five against integration, with most pertaining to clinical care, the organizational context, process, and purpose. Given that health care providers may find EHR changes to be disruptive to workflow and an imposition to day-to-day activities, engaging end-users in decision-making processes surrounding forthcoming EHR changes may not only increase investment in them, but also prevent provider burnout.

Hospitalist and specialist role differentiation: patients, practice patterns, and performance

Background: While the field of hospital medicine has grown since its establishment in the 1990s, much of the research on these inpatient physicians has been grounded in comparisons to community-based providers. Little is known about how hospitalists have differentiated themselves from other inpatient physicians. Purpose: This study explores how hospitalists compare to other inpatient physicians for patient cases of overlapping expertise, focusing on differences in patient populations, practice patterns, and performance on cost and quality metrics. Methodology: We use mixed effect multilevel models and mediation models to analyze disaggregated billing data for all relevant admissions to a large urban pediatric hospital occurring between January 1, 2009, and August 31, 2015. Results: In areas of overlapping physician expertise, patients with more ambiguous diagnoses and multiple chronic conditions have higher likelihood of being assigned to a hospitalist. Controlling for differences in patient populations, hospitalists order laboratory tests and medications at lower rates than specialists. Hospitalists’ lower laboratory test order rate had a significant mediating role in hospitalists’ lower total charges and lower odds of their patients experiencing any non-surgical adverse events compared to specialists, though hospitalists did not differ from specialists in 30- and 90-day readmission rates. Practice Implications: For inpatient cases that can be treated by either hospitalists or other specialists, assigning patients to hospitalists is associated with more efficiency and lower rates of adverse events. Decision rules on physician assignment should consider these potential benefits to patients given case type and practice pattern differences between hospitalists and specialists.

“We’re Moving in the Right Direction. Still a Long Way to Go”: Experiences and Perceptions of the Climate for LGBTQ+ Employees at a Pediatric Hospital

ABSTRACT A positive LGBTQ+ (lesbian, gay, bisexual, transgender/nonbinary, queer) workplace climate is critical for healthcare employee satisfaction, productivity, and patient care. The current study assessed LGBTQ+ workplace climate among 791 employees from a large urban pediatric hospital. Several workplace climate domains were assessed in an online survey: employee attitudes, training, experiences related to working with LGBTQ+ colleagues, patients and families, and LGBTQ+-specific experiences. For most domains, half or more of respondents perceived an affirming LGBTQ+ climate. LGBTQ+ employees perceived a less affirming climate than cisgender heterosexual employees. LGBTQ+ employees, especially transgender/nonbinary employees, experienced numerous discriminatory situations. Over 90% of participants felt competent and qualified to work with LGB patients/families; 80% felt competent and qualified to work with TNB patients/families. Themes from open-ended survery responses reflected three LGBTQ+ climate components: systemic, interpersonal, and “grassroots” (affinity group) initiatives. Findings inform strategies to improve LGBTQ+ employee experiences and competency caring for LGBTQ+ patients and families.

Illustrating the value of social work: results of an open pilot trial of the psychosocial acuity scale in a large urban pediatric hospital

ABSTRACT While Electronic Medical Records (EMRs) are an important mechanism used to document patient information and service provision, most interfaces prioritize collection of information required for medical billing purposes, rather than complexities of behavioral and social service needs. An emphasis on encounter data renders it challenging for social workers (SWs) to communicate statistically compelling explanations of contributions to team-based care and overall value to the health system. This paper reports outcomes of feasibility, acceptability, and appropriateness of integrating a validated psychosocial acuity metric into standardized social work (SW) documentation at a large, pediatric quaternary hospital in the northeastern United States. Approximately 20% (N = 42) of departmental SWs participated in an open pilot trial wherein participants were first trained in scale administration, utilized it for a circumscribed period following training, and evaluated implementation outcomes. Across five unique practice settings, results showed that the metric was feasible, acceptable and appropriate for use; 78% of participants were in favor of integrating it into the EMR interface as a required component of SW documentation. Assessing psychosocial acuity in every documented patient encounter facilitates intermittent review of psychosocial acuity at individual, setting, and programmatic levels and opportunities to evaluate how SW interventions address psychosocial acuity.

#87: Association Between Healthcare-Associated Respiratory Viral Infections and Length of Stay at a Pediatric Hospital

Abstract Background Healthcare-associated infections (HAI) are major preventable causes of morbidity and mortality. While there are fewer overall HAI in children, there is a greater potential impact in disability-adjusted life years. Healthcare-associated respiratory viral infections (HARVI) are not frequently tracked within institutions, yet the risk for such infections in pediatric hospitals is very high. Recent data demonstrate large inter-hospital variability of HARVI incidence that may depend on various factors including the number of immunocompromised patients in the hospital and the presence of shared rooms. We hypothesize that the burden of healthcare-associated respiratory viral infections and their impact on the length of stay (LOS) is substantial at a large urban pediatric hospital. Methods A cohort of all children with any HARVI admitted to a large urban pediatric hospital between July 2017 and June 2018 were included after obtaining IRB approval. We defined a HARVI as a respiratory infection with an onset of symptoms while the patient was hospitalized meeting three criteria: A positive microbiologic test for one of 8 viruses, presence of symptoms of a respiratory infection, and onset of symptoms after admission beyond the minimum incubation period for each virus. Infections with symptom onset after admission beyond the maximum incubation period were considered definite hospital onset whereas others were considered possible hospital onset. The electronic medical record provided data on demographics, underlying medical conditions, hospital length of stay prior to infection and hospital unit of infection, and consequences and outcome of HARVI. The at-risk population for calculation of the incidence of HARVI was all admitted patient-days at the hospital over this time period. Results Between July 2017 and June 2018 the incidence of HARVI (definite or possible hospital onset) was 1.2 infections per 1,000 admitted patient-days (60% due to rhinovirus/enterovirus, 12% due to respiratory syncytial virus, and 9% due to influenza). Overall, 48% of patients were under 2 years of age, 18% were between 2 and 5 years of age, and 34% were over 5 years of age. Twenty-one percent were immunocompromised and 35% had underlying lung disease. The median length of stay prior to symptom onset was 11 days (IQR 5–36 days) and the median total length of stay was 30 days (IQR 15–82.5 days). Eight individuals had more than one HARVI over this time period. Nineteen percent were transferred to the intensive care unit and 7% died during their hospital admission Conclusion HARVI occurs frequently in a pediatric hospital and often in patients with underlying comorbidities. The risk for HARVI increases substantially with increased length of stay. Such data support the need for tracking HARVI in high-risk institutions.

Implementing an inpatient integrative medicine consult service for children with pain: A qualitative analysis

ObjectivesComplementary and integrative medicine (CIM) therapies show clinical benefits with minimal side effects, yet challenges to effective integration in hospital settings remain. The current study aimed to better understand the process of integration of CIM therapies at a large urban pediatric hospital from the perspectives of providers, parents, and administrators. DesignThe study employed an applied medical ethnography. SettingThe ethnography was conducted before, during, and after an Integrative Medicine Pain Consult Service (IM Pilot) was implemented at a large urban pediatric hospital during the spring of 2017. Main outcome measuresFieldwork interviews, participant observations, and document review captured aspects of the integration of CIM over a 6-month study period. Ethnographic analysis included thematic content analysis. Participants included providers (n = 10), administrators (n = 5), and parents of patients (n = 11). ResultsEmergent themes from analysis of the interviews and field notes were organized according to the socio-ecological model. Themes included facilitating factors for CIM pain management at the intrapersonal and community levels (Alignment with Parental Perceptions of Child Needs and Provider Desire to Offer Care, Alignment of CIM with Spiritual Beliefs and Community Norms) and barriers at the interpersonal, organizational, and political levels (Inter-professional Challenges, Lack of Logistics in Place for Referrals and Triaging Patients with Pain, Lack of Remuneration/Insurance Reimbursement for Care). ConclusionsTo address barriers, future efforts to implement integrative pain management programs in pediatric hospital settings may consider testing implementation strategies, including engaging program champions and family advocates, providing education on CIM professions and therapies to hospital staff, and billing for provider time rather than individual CIM therapies.

Treatment Strategies by Training Specialty: Patient Consequences of Hospitalist and Specialist Practice Patterns

Although hospitalists (generalist inpatient physicians) have overlapping functions and expertise with specialist physicians, practice differences and resulting patient outcomes between the physician types are not well understood. We investigate how hospitalists and inpatient specialists differ in their treatment strategies and how such differences are associated with patient outcomes. Our identification strategy focuses on a subset of common conditions treated by both hospitalists and specialists within a single hospital such that the setting and organizational policies are the same for both physician types.We use a two‐stage design to disentangle differences in both practice patterns and patient outcomes. In the first stage, we explore whether hospitalists and specialists differ in the number of laboratories and drugs ordered using multilevel negative binomial generalized linear models, accounting for both the distribution of the data and the nesting of patients within providers. We control for patient characteristics, provider workload, and details of the admission including length of stay and any use of intensive care.In the second stage, we model the likelihood that a patient experiences an adverse event or a readmission. These multilevel logistic models expand upon the first‐stage control variables to include the number and types of laboratories and drugs ordered.We leverage data on physicians and patients in a large urban pediatric hospital between January 1, 2009, and August 31, 2015. By focusing on 57 diagnoses commonly treated by both hospitalists and specialists, we are able to distinguish differences in treatment patterns and outcomes for similar patient cases.Practice patterns differ significantly between hospitalists and specialists, and these differences are subsequently associated with differences in patient outcomes. Over the median 3‐day hospital stay, hospitalists ordered 5.0 fewer laboratories (31.3%, P &lt; .001) compared to specialists for conditions identified as well‐known (ie, conditions with clear diagnosis and treatment protocols) and 6.3 fewer laboratoriess (45.1%, P &lt; .001) for less well‐known conditions. Drug orders follow a similar pattern, with hospitalists placing 2.0 fewer orders (11.4%, P = .002) for well‐known conditions and 8.9 fewer orders (46.9%, P = .002) in less well‐known conditions. Specialists are associated with a 3.2 percentage point higher likelihood of patients’ experiencing an adverse drug event (P &lt; .001) and a 5.3 percentage point higher probability of a patient experiencing any adverse event (P &lt; .001). We find no differences in readmission rates.Patients are likely to receive substantially different treatment based on whether they are treated by hospitalists or specialists. Compared to specialists, hospitalists order fewer laboratories and drugs. These patterns are associated with increased costs and reduced adverse events, with no corresponding change in readmission rates.Hospitalists are able to perform similarly or better than specialists on key quality outcomes, despite fewer orders for laboratories and drugs. Efforts to mitigate medical overuse must recognize these differences in practice across specialties, so as to better target the source of inefficient treatment strategies.

Implementation of a pediatric/adolescent suicide risk screening tool for patients presenting to the Emergency Department with nonbehavioral health complaints.

At a large urban pediatric hospital, from 2015 to 2016, a 44% increase occurred in youth with suicide attempts admitted to medical units. At that time, patients assessed in the Emergency Department (ED) were asked one question to determine suicide risk. The Iowa Model served as the framework for the Psychiatry and Emergency Departments to identify an evidence-based suicide screening tool and educate/train all ED nurses on assessing patients for suicide risk. In July 2017, ED nurses began assessing all patients (ages 10 and over) utilizing the Ask Suicide-Screening Questions (ASQ). In the first 3 months of ASQ implementation, 390 youth were identified in the ED as struggling with sadness/worry or at risk for suicide. Pre-intervention ED nurses' survey results indicated 30% felt inadequately trained in suicide screening; 26% considered the ASQ too time consuming, and 40% agreed there was stigma regarding mental health. Post-education ED nurses' survey results showed improvement in skills (64% felt adequately trained) but there was no significant change in mental health stigma perception. Within the first 3 months of assessing all nonbehavioral patients ages 10 and over, there was a 37% increase of ED patients identified as a suicide risk, enabling immediate mental health assessments before suicide attempts.

Medical Clearance Prior to Psychiatric Evaluation in a Tertiary Pediatric Emergency Department: Value and Cost Analysis

Background: Medical clearance in the emergency department for patients undergoing psychiatric evaluation is often required prior to admission to rule out organic cause and because many psychiatric facilities are unable to treat medical conditions. This may be low yield in pediatric populations as the likelihood of disease requiring intervention is low in this setting.&#x0D; Objectives: To determine whether routine laboratory testing in an urban, tertiary pediatric hospital emergency center impacted the overall management of patients presenting with chief complaints requiring psychiatric evaluation.&#x0D; Methods: Retrospective analysis of all psychiatric admissions over a one year period at a large urban tertiary pediatric hospital. Laboratory test results were compared with history and physical notes to determine whether abnormal results could have been anticipated based on patient report. Additional medical interventions required and overall impact on management was recorded. Cost analysis was based on public reimbursement rates, considering tests without impact on intervention to be unnecessary.&#x0D; Results Overall, 1824 tests laboratory tests were performed in 289 patients admitted for psychiatric treatment. There were 161 abnormal results (8.8%), most of which could be anticipated by the medical history. No abnormal result laboratory result led to a change in management for any patient. The sensitivity and negative predictive value for patient-reported drug use compared to urine drug screen results were high, both over 90%.&#x0D; Conclusions Medical clearance in this population is low yield; most abnormal results can be anticipated by patient report or do not require any clinical intervention. The cost of these unnecessary tests was over $500,000.

Moral Distress: Defined and Described by Neonatal and Pediatric Critical Care Nurses in a Quaternary Care Free-Standing Pediatric Hospital.

Despite a growing population of chronically and acute critically ill neonatal and pediatric patients, there were few published articles related to moral distress as experienced by nurses caring for these patients. The aim of this study was to define moral distress based on the perceptions and experiences of neonatal and pediatric critical care nurses. A qualitative descriptive study using focus group methodology was undertaken. All nurses with 2 or more years of experience from the 4 neonatal and pediatric intensive care units in a large 404-bed urban pediatric hospital located in the northeast were invited to attend 1 of 15 audio-recorded focus groups lasting 60 to 90 minutes. Once data were transcribed, conventional content analysis was used to develop the definition and categories of moral distress. Nurse participants defined moral distress as "patient care situations where there is a mismatch or incongruity between expected behaviors of the nurse and his/her personal values/beliefs in the neonatal/pediatric critical care setting." The 2 overarching categories that emerged from the data were patient-focused factors and nurse-focused factors. Understanding how neonatal and pediatric critical care nurses define moral distress and what contributes to its development is foundational to developing targeted strategies for nursing support and education, with the goal of creating a culture of moral resiliency.