Le Bonheur Children Research Articles

Intranasal Fentanyl and Midazolam for Procedural Analgesia and Anxiolysis in Pediatric Urgent Care Centers.

Intranasal fentanyl and midazolam use is increasing in the acute care setting for analgesia and anxiolysis, but there is a lack of literature demonstrating their use, alone or in combination, at pediatric urgent care centers. This retrospective study investigated intranasal fentanyl and midazolam use at an urgent care center located within Le Bonheur Children's Hospital and 2 affiliated off-site centers from September 22, 2011, to December 30, 2015. Data collected included patient demographics, initial fentanyl dose, initial midazolam dose, type of procedure, and serious adverse drug reactions. Of the 490 patients who met the inclusion criteria, 143 patients received intranasal fentanyl alone, 92 received intranasal midazolam alone, and 255 received fentanyl in combination with midazolam. The overall patient population was 50% male with a median (range) age of 4.5 (0.2-17.9) years, and most patients were black at 57.1%. The median (range) initial intranasal fentanyl dose was 2.02 (0.99-4.22) μg/kg, and the median initial (range) intranasal midazolam dose was 0.19 (0.07-0.42) mg/kg. In cases where fentanyl and midazolam were administered in combination, the median (range) initial fentanyl dose was 2.23 (0.6-4.98) μg/kg and median (range) initial midazolam dose was 0.2 (0.03-0.45) mg/kg. There were no serious adverse drug reactions reported. Intranasal fentanyl and midazolam when administrated alone and in combination can provide analgesia and anxiolysis for minor procedures in pediatric patients treated in the urgent care setting.

Unstructured Text in EMR Improves Prediction of Death after Surgery in Children

Text fields in electronic medical records (EMR) contain information on important factors that influence health outcomes, however, they are underutilized in clinical decision making due to their unstructured nature. We analyzed 6497 inpatient surgical cases with 719,308 free text notes from Le Bonheur Children’s Hospital EMR. We used a text mining approach on preoperative notes to obtain a text-based risk score to predict death within 30 days of surgery. In addition, we evaluated the performance of a hybrid model that included the text-based risk score along with structured data pertaining to clinical risk factors. The C-statistic of a logistic regression model with five-fold cross-validation significantly improved from 0.76 to 0.92 when text-based risk scores were included in addition to structured data. We conclude that preoperative free text notes in EMR include significant information that can predict adverse surgery outcomes.

Pneumococcal Polysaccharide Vaccination in Pediatric Inflammatory Bowel Disease.

According to current recommendations, in addition to 13-valent pneumococcal conjugate vaccine (PCV13) series, all children with inflammatory bowel disease (IBD) aged ≥2 years, with planned or current immunosuppression, should receive pneumococcal polysaccharide vaccine (PPSV23). The primary aim was to determine the PPSV23 immunization rates in our pediatric IBD patients. The secondary aim was to determine the incidence of invasive pneumococcal disease in these patients. The IBD database at Le Bonheur Children’s Hospital was retrospectively reviewed to identify all cases diagnosed from 2003 to 2015. Out of 190 IBD patients, 106 on immunosuppressive drugs, whose immunization records could be obtained from the state database, were included in the study. Medical records were reviewed to determine infections seen in these patients from the time of diagnosis to date. IBD patients in our study ranged from age 2 to 18 years. Only 4 of 106 (3.7%) patients had received PPSV23 vaccine. Only 1 patient (0.9%) had probable pneumococcal disease and none with invasive pneumococcal disease. Clostridium difficile (11 patients) and Cytomegalovirus colitis (4 patients) were more commonly encountered. All our patients received the recommended PCV13 vaccine. The majority of our pediatric IBD patients did not receive PPSV23 vaccine. Fortunately, we did not see a high rate of invasive pneumococcal disease in our patients suggesting that they may be protected by the primary PCV13 vaccine series. Non-pneumococcal infections were more common in this population.

Decreasing Racemic Epinephrine for Bronchiolitis in an Academic Children's Hospital.

Bronchiolitis is a leading cause of pediatric hospitalizations in the United States. Although the American Academy of Pediatrics recommends against routine use of bronchodilators in bronchiolitis management, racemic epinephrine was persistently used for this purpose at Le Bonheur Children's Hospital. Our aim was to decrease racemic epinephrine use for bronchiolitis by 50% within 8 months. Our multidisciplinary team used the Institute for Healthcare Improvement's Model for Improvement to develop an aim statement, choose metrics, and perform plan-do-study-act cycles to reduce racemic epinephrine use. We used focused education through in-person and online methods and provided direct feedback to residents, respiratory therapists, and nurses primarily caring for these children. The percentage of all patients admitted for bronchiolitis receiving at least 1 dose of racemic epinephrine was collected from the medical record and recorded on statistical process control charts for distribution to their work areas. Albuterol use and length of stay were collected as balancing measures. We used statistical process control charts to establish special cause variation and identify statistically significant differences in our measures. During our intervention period, the percentage of bronchiolitis patients receiving at least 1 dose of racemic epinephrine to treat bronchiolitis decreased from an average of 26% to 5%, and similarly, albuterol use decreased from an average of 48% to 34%. There was no clinically significant difference in length of stay. Using a multidisciplinary approach and focused education techniques may be an effective way to reduce racemic epinephrine use for children with bronchiolitis.

Biorepository and integrative genomics initiative: designing and implementing a preliminary platform for predictive, preventive and personalized medicine at a pediatric hospital in a historically disadvantaged community in the USA.

Current healthcare is evolving to emphasize cost-effective care by leveraging results and outcomes of genomic and other advanced research efforts in clinical care and preventive health planning. Through a collaborative effort between the University of Tennessee Health Science Center (UTHSC) and Le Bonheur Children's Hospital (LBCH), the Biorepository and Integrative Genomics (BIG) Initiative was established to set up a pediatric-based DNA biorepository that can serve as a foundation for successful development of delivery platforms for predictive, preventive, and personalized medical services in Memphis, Tennessee, a historically disadvantaged community in the USA. In this paper, we describe the steps that were followed to establish the biorepository. We focused on domains that are essential for implementation of a biorepository for genomic research as an initial goal and identified patient consent, DNA extraction, storage and dissemination, and governance as essential components. Specific needs in each of these domains were addressed by respective solutions developed by multidisciplinary teams under the guidance of a governance model that involved experts from multiple hospital arenas and community members. The end result was the successful launch of a large-scale DNA biorepository, with patient consent greater than 75% in the first year. Our experience highlights the importance of performing pre-design research, needs assessment, and designing an ethically vetted plan that is cost-effective, easy to implement, and inclusive of the community that is served. We believe this biorepository model, with appropriate tailoring according to organizational needs and available resources, can be adopted and successfully applied by other small- to mid-sized healthcare organizations.

Abstract WP390: Mechanical Thrombectomy and Intravenous Tissue Plasminogen Activator in Pediatric Arterial Ischemic Stroke: Lessons From a Case Series

Introduction: Stroke is one of the 10 most common causes of death in children. With no randomized studies in children on safety in efficacy, use of tissue plasminogen activator(tPA) and mechanical thrombectomy is limited. Consensus based guidelines are available for the use of thrombolysis in children with arterial ischemic stroke(AIS). Objective: a.) Retrospectively review and analyze patients who had either IV tPA or mechanical thrombectomy or both b.) compare with similar studies Methodology: Study was conducted at Le Bonheur Children’s Hospital in Memphis TN. Data collected as part of International Pediatric Stroke Study, starting from January 2016 until March 2017(15 months) were reviewed retrospectively. Literature review was conducted to compare results. All patients included had at least one follow up after 3 months after the treatment. Results: Out of 38 patients diagnosed to have AIS, four of them (10 %) underwent either tPA or mechanical thrombectomy or both. Age ranged from 14 to 17 years. Pediatric NIH stroke scale on arrival ranged from 6-9. Dose of tPA as well as inclusion and exclusion criteria was based on Thrombolysis in Pediatric Stroke(TIPS) study. All of them had MRI or CT angiogram detection of stroke and arterial occlusion before the procedure. Duration of symptoms to the initiation of one the hyper-acute treatment was 3.5 to 4.5 hours in all except one who underwent thrombectomy for basilar artery thrombosis. One got only tPA thrombolysis, two had both tPA followed by mechanical thrombectomy and the fourth, had basilar artery thrombosis, underwent only thrombectomy with suction as the patient arrived beyond 4.5 hours’ window. No complications were noticed. On follow up after 3 months, 3 out four had full recovery.The fourth patient still had expressive aphasia and cognitive deficits who on MRI head with contrast was found to have persistent enhancement in the cortical area suggestive of vasculitis. Conclusion: In conclusion, 10% of total AIS patients, underwent IV thrombolysis or mechanical thrombectomy and had no complication; similar data was reported in prior studies. However,randomized controlled trials would be necessary to substantiate the validity or reliability of the use of IV tPA or mechanical thrombectomy in pediatric AIS.

Decreased Identification of Vesicoureteral Reflux: A Cautionary Tale.

To find the trend in patient's visits to our centers for vesicoureteral reflux (VUR). We hypothesize that VUR diagnosis and hence possible nephropathy recognition may be diminishing because of changing practice patterns. Data were extracted from electronic medical records for new and follow-up patients aged 0-18 years with ICD-9/10 codes to correspond with VUR, VUR unilateral, VUR bilateral, and VUR with reflux nephropathy, as well as new patients with diagnoses of urinary tract infections (UTI) and pyelonephritis at two major pediatric centers from 2012 to 2015. Figures and statistics to reflect absolute clinic visits and annual trends were created with SPSS 2010. Linear regression was applied. Annually, Le Bonheur Children's Hospital and Nationwide Children's Hospital experienced an average decrease of 13 and 17% in total VUR visits, and an average decrease of 22 and 27% in VUR nephropathy visits, respectively, for each institution. Patient visits for UTIs were reduced an average of 16% annually in both centers. Linear regression demonstrated that number of patients (patients/year ± SE) decreased annually 69 ± 19 (P = 0.02), 7 ± 2 (P = 0.02), and 67 ± 25 (P = 0.04) for VUR, VUR nephropathy, and UTI, respectively. We conclude that the decreased number of VUR and VUR nephropathy cases identified in subspecialty clinics (Nephrology/Urology) at two major children's hospitals reflect a possible decreased identification of VUR. This trend may also be due to decreased referral of low grade cases of VUR. We cannot conclude that "undifferentiated UTI" referrals increased concomitantly to account for the decreased VUR as our data reflects a decreased trend in those visits as well. We suggest that clinicians following the American Academy of Pediatrics guidelines ensure that all UTI are accounted for and surveillance is appropriately escalated for recurrent UTI or abnormal imaging results.

Effectiveness Of A Low-cost Exercise Intervention For Pediatric Obesity

PURPOSE: Regular physical activity improves health profiles and quality of life in youth with obesity (YWO), and participation in sport-specific events reportedly improves self-efficacy among youth with little athletic experience. This project retrospectively evaluated the feasibility and efficacy of an ongoing low-cost physical activity intervention to prepare YWO for an athletic event (5K run/walk). METHODS: The Healthy Lifestyle Clinic (HLC), a multidisciplinary weight management clinic at Le Bonheur Children’s Hospital, hosted a race team for a 5K run/walk event. HLC patients were offered a training program designed to be engaging, minimally burdensome for clinical staff, and focused on preparing exercise-naïve YWO to complete a 5K. Training included 3 weekly aerobic sessions (20-45 minutes) with duration and intensity increased based on rating of perceived exertion. Participants completed workout logs and were invited to workouts in the community with HLC staff members. Weekly phone calls were made to monitor progress, engagement, and individualize the program. On average, phone calls lasted <10 minutes. Retrospective review of medical records and patient communications, was IRB approved. RESULTS: Initially 28 YWO expressed interest in the training program. Twelve YWO (11.4±2.6 yrs, 151.3.4±13.3 cm tall, 88±24.5 kg, 99.1±0.76 BMI %ile) actively engaged (reporting >70% adherence) with the training, and 6 participants completed the 5K race (all 1st time racers). Almost 60% of participants attended all community workouts and those who completed the 5K had greater parent engagement than those who did not. Similarly, those who engaged in more frequent phone contact were more engaged in the training program. More than 80% of families who participated requested the program become a recurring HLC offering, indicating a desire for more exercise interventions. Themes of improved physical appearance, self-worth, and athletic competence emerged from patient reports. All those who completed the race expressed likelihood to attempt another race. CONCLUSIONS: This program was feasible, minimally burdensome, and cost-effective. It had a positive effect on self-reported motivation, physical fitness, and self-efficacy. Parental involvement was a driving factor for program adherence and race completion.

Improving Patient Safety: Standardizing Physician Notification of Patient Arrival

Le Bonheur Children’s Hospital is a 255-bed stand-alone children’s hospital in Memphis, Tennessee. The pediatric residents admit the majority of general pediatric and subspecialty patients. Upon the patient’s arrival to the floor, the admitting team is to be notified. There was a patient safety event related to a breakdown in communication to the admitting team which resulted in a review of the notification process. We discovered there was not a uniform notification process among the different units once the patient arrived to the floor.

The Preventable Shunt Revision Rate: a potential quality metric for pediatric shunt surgery.

OBJECTIVE Shunt surgery consumes a large amount of pediatric neurosurgical health care resources. Although many studies have sought to identify risk factors for shunt failure, there is no consensus within the literature on variables that are predictive or protective. In this era of "quality outcome measures," some authors have proposed various metrics to assess quality outcomes for shunt surgery. In this paper, the Preventable Shunt Revision Rate (PSRR) is proposed as a novel quality metric. METHODS An institutional shunt database was queried to identify all shunt surgeries performed from January 1, 2010, to December 31, 2014, at Le Bonheur Children's Hospital. Patients' records were reviewed for 90 days following each "index" shunt surgery to identify those patients who required a return to the operating room. Clinical, demographic, and radiological factors were reviewed for each index operation, and each failure was analyzed for potentially preventable causes. RESULTS During the study period, there were 927 de novo or revision shunt operations in 525 patients. A return to the operating room occurred 202 times within 90 days of shunt surgery in 927 index surgeries (21.8%). In 67 cases (33% of failures), the revision surgery was due to potentially preventable causes, defined as inaccurate proximal or distal catheter placement, infection, or inadequately secured or assembled shunt apparatus. Comparing cases in which failure was due to preventable causes and those in which it was due to nonpreventable causes showed that in cases in which failure was due to preventable causes, the patients were significantly younger (median 3.1 vs 6.7 years, p = 0.01) and the failure was more likely to occur within 30 days of the index surgery (80.6% vs 64.4% of cases, p = 0.02). The most common causes of preventable shunt failure were inaccurate proximal catheter placement (33 [49.3%] of 67 cases) and infection (28 [41.8%] of 67 cases). No variables were found to be predictive of preventable shunt failure with multivariate logistic regression. CONCLUSIONS With economic and governmental pressures to identify and implement "quality measures" for shunt surgery, pediatric neurosurgeons and hospital administrators must be careful to avoid linking all shunt revisions with "poor" or less-than-optimal quality care. To date, many of the purported risk factors for shunt failure and causes of shunt revision surgery are beyond the influence and control of the surgeon. We propose the PSRR as a specific, meaningful, measurable, and-hopefully-modifiable quality metric for shunt surgery in children.

Home-Based Palliative Care: Translating a Research Model into a Primary Care Benefit (FR457)

Palliation Beyond Death: Face-to-Face Interdisciplinary Postmortem Review as a Tool to Mitigate Complicated Bereavement and Promote Legacy Building (FR456) Erica Kaye, MD, St. Jude Children’s Research Hospital, Memphis, TN. Daniel Mahoney, MD FAAP, Le Bonheur Children’s Hospital, Memphis, TN. Joanna Lyman, MA CCLS, Le Bonheur Children’s Hospital, Memphis, TN. Melody Cunningham, MD, Le Bonheur Children’s Hospital, Memphis, TN.

Title: An MEG evaluation of the dual-route model on language

Title: An MEG evaluation of the dual-route model on language

Dichotomy of Tenure and Biomedical Engineering Research with a Purpose in an Academic Setting

I am one of the many biomedical engineering researchers whose work is built on strong interactions with physicians and basic scientists who find value in the way we approach healthcare problems from alternate perspectives. For example, I collaborated with multiple lung critical care physicians in the past 5 years, one of whom was a pediatric critical care physician at a children’s hospital in Memphis, TN, USA. We met regularly in lung physiology research meetings organized by our mentor to discuss problems relating to pediatric lung health, and we carried out research activities to understand the role of mechanobiology of potassium channels in the context of mechanical ventilation (1, 2). In addition to these types of research collaborations, biomedical engineers in academia contribute to the healthcare of pediatric patients also via design initiatives. Just yesterday, I listened to a set of senior design projects that displayed prototypes of at-home mechanical ventilator systems for young children aimed to increase their mobility. These projects were based on collaborations established between the therapists, clinicians, and professors at multiple institutions (Le Bonheur Children’s Hospital, University of Memphis, University of Tennessee Health Science Center). As such, most would agree with me in saying that these collaborations are important and necessary to develop and optimize healthcare solutions.

Implication of Auto-Anti-U Antibody in a Pediatric Patient

The anti-U antibody is a rare antibody belonging to the MNS blood group system and has been implicated in cases of hemolytic transfusion reaction and hemolytic disease of the fetus and newborn (HDFN). We report a case of auto-anti-U antibody in a pediatric patient. A 14-year-old African American girl, G0, with a 4-week history of bloody diarrhea, was admitted to Le Bonheur Children’s …

What is the risk of a shunt malfunction after elective intradural surgery?

Surgery for CSF diversion is the most common procedure performed by pediatric neurosurgeons. The failure rates for shunts remain frustratingly high, resulting in a burden to patients, families, providers, and healthcare systems. The goal of this study was to quantify the risk of a shunt malfunction in patients with an existing shunt who undergo an elective intradural operation. All elective intradural surgeries (cranial and spinal) at Le Bonheur Children's Hospital from January 2010 through June 2014 were reviewed to identify those patients who had a functional ventricular shunt at the time of surgery. Patient records were reviewed to collect demographic, surgical, clinical, radiological, and pathologic data, including all details related to any subsequent shunt revision surgery. The primary outcome was all-cause shunt revision (i.e., malfunction or infection) within 90 days of elective intradural surgery. One hundred and fifty elective intradural surgeries were identified in 109 patients during the study period. There were 14 patients (12.8%, 13 male) who experienced 16 shunt malfunctions (10.7%) within 90 days of elective intradural surgery. These 14 patients underwent 13 craniotomies, 2 endoscopic fenestrations for loculated hydrocephalus, and 1 laminectomy for dorsal rhizotomy. Median time to failure was 9 days, with the shunts in half of our patients failing within 5 postoperative days. Those patients with failed shunts were younger (median 4.2 years [range 0.33-26 years] vs median 10 years [range 0.58-34 years]), had a shorter time interval from their previous shunt surgery (median 11 months [range 0-81 months] vs median 20 months [range 0-238 months]), and were more likely to have had intraventricular surgery (80.0% vs. 60.3%). This is the first study to quantify the risk of a shunt malfunction after elective intradural surgery. The 90-day all-cause shunt failure rate (per procedure) was 10.7%, with half of the failures occurring within the first 5 postoperative days. Possible risk factors for shunt malfunction after elective intradural surgeries are intraventricular surgical approach, shorter time since last shunt-related surgery, and young age.

Harnessing the power of advanced hospital pharmacy technicians to improve patient care

Pharmacy technician roles have evolved rapidly over the past 40 years. At Le Bonheur Children's Hospital in Memphis, TN, technicians have taken on innovative and advanced roles that range from disease specialization to administration.

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1Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN 2Department of Pediatrics, Le Bonheur Children’s Hospital, Memphis, TN

Head injuries following television-related accidents in the pediatric population.

Current data indicate the rate of head injuries in children caused by falling televisions is increasing. The authors describe these injuries and the cost incurred by them. In a single-institution retrospective review, all children treated for a television-related injury at LeBonheur Children's Hospital, a Level I pediatric trauma center, between 2009 and 2013 were identified through the institution's trauma registry. The type, mechanism, and severity of cranial injuries, surgical interventions, outcome, and costs were examined. Twenty-six patients were treated for a television-related injury during the study period. Most injuries (22 cases, 85%) occurred in children aged 2-4 years (mean age 3.3 years), and 19 (73%) of the 26 patients were male. Head injuries occurred in 20 patients (77%); these injuries ranged from concussion to skull fractures and subdural, subarachnoid, and intraparenchymal hemorrhages. The average Glasgow Coma Scale score on admission was 12 (range 7-15), and 3 patients (12%) had neurological deficits. Surgical intervention was required in 5 cases (19%). The majority of patients made a full recovery. There were no deaths. The total cost for television-related injuries was $1.4 million, with an average cost of $53,893 per accident. A high occurrence of head injuries was seen following television-related accidents in young children. This injury is ideal for a public education campaign targeting parents, health care workers, and television manufacturers.

New pharmacists: Take care of those babies

As a hospital pharmacy resident in 1979–80, I never missed an opportunity to round in pediatrics. Even though "clinical" was just a few weeks of my yearlong experience at the University of Texas Medical Branch (UTMB) at Galveston, I followed one of the pediatric teams all year, changing service when they did and showing up for rounds at 7:00am on any morning when I could take the beeper and slip away from my assigned area.

Pediatric pharmacist draws inspiration from young patients

Michael L. Christensen, PharmD, has dedicated his career to helping kids feel better. He divides his time between caring for young patients with parenteral nutrition needs and working as the principal investigator on clinical trials focused on understanding the pharmacokinetics of various medications in pediatric populations. "The best thing about being in pediatrics is that everyone cares about the children and wants what's best for them," said Christensen, Clinical Pharmacy Specialist at Le Bonheur Children's Hospital in Memphis, TN.