Mott Children Research Articles

Barriers and facilitators to effective electronic health record-based sepsis screening in the pediatric intensive care unit.

The Pediatric Surviving Sepsis Campaign supports the implementation of automated tools for early sepsis recognition. In 2019 the C.S. Mott Children's Hospital Pediatric Intensive Care Unit deployed an electronic medical record (EMR)-based screening for early recognition and treatment of sepsis. We analyzed all automated primary sepsis alerts, secondary screens, and bedside huddles from November 2019 to January 2020 (Cohort 1) and from November 2020 to January 2021 (Cohort 2) to identify barriers and facilitators for the use of this tool. We distributed surveys to frontline providers to gather feedback on end-user experience. In Cohort 1, 895 primary alerts were triggered, yielding 503 completed secondary screens and 40 bedside huddles. In Cohort 2, 925 primary alerts were triggered, yielding 532 completed secondary screens and 12 bedside huddles. Surveys assessing end-user experience identified the following facilitators: (1) 73% of nurses endorsed the bedside huddle as value added; (2) 74% of medical providers agreed the bedside huddle increased the likelihood of interventions. The greatest barriers to successful implementation included the (1) overall large number of primary alerts from the automated tool and (2) rate of false alerts, many due to routine respiratory therapy interventions. Our data suggests that the successful implementation of EMR-based sepsis screening tools requires countermeasures focusing on 3 key drivers for change: education, technology, and patient safety. While both medical providers and bedside nurses found merit in our EMR-based sepsis early recognition system, continued refinement is necessary to avoid sepsis alert fatigue.

Establishing Real-World Data-Driven Response Criteria in Pediatric Acute Myeloid Leukemia

Introduction: Disease response criteria in pediatric acute myeloid leukemia (pAML) include complete remission (CR), complete remission without platelet count recovery (CRp), and complete remission with incomplete count recovery (CRi). Although clinicians use CR, CRp, and CRi as valid endpoints, the FDA only accepts CR as a valid response endpoint with the Cheson/European Leukemia Network (ELN) response criteria of absolute neutrophil count (ANC) >1,000 and platelets >100,000. Recent adult data show improved survival in patients achieving CR relative to CRp or CRi. Pediatric data from the Children's Oncology Group (COG) demonstrate similar survival regardless of achieving an ANC >500 or platelets >50,000. However, actual ANC and platelet data were not known, and COG data may not reflect outcomes of patients treated off study. Exclusion of CRp and CRi as valid efficacy endpoints limits clinical trials by potentially excluding patients who achieve remission but proceed to subsequent chemotherapy prior to meeting ELN recovery criteria. To address this data gap, we defined the ANC and platelet count trajectories in a 13-day window at end of course bone marrow (BM) after Induction I/II and Reinduction I/II of relapse therapy. We compared disease-free (DFS) and overall survival (OS) among CR categories and hypothesized that CR, CRp, and CRi after Induction I and Reinduction I would be associated with similar DFS and OS. Methods: Newly diagnosed pAML patients from 2011-2022 with at least one frontline chemotherapy course at one of six pediatric centers (Children's Hospital of Philadelphia, Children's Healthcare of Atlanta, Children's Hospital of Michigan, C.S. Mott Children's Hospital, Lurie Children's Hospital, and Texas Children's Hospital) underwent manual chart abstraction to capture demographic, therapy, toxicity, and BM response data: morphologic and minimal residual disease (MRD). The highest daily ANC and platelet counts were abstracted ±13 days around the last BM aspirate after Induction I/II and reinduction I/II post relapse. ELN and COG recovery criteria for ANC (>1,000 and >500, respectively) and platelet (>100,000 and >50,000, respectively) defined CR, CRp and CRi; CRi was further divided into CRnoANC and CRnoANCnoPlatelet. Standard descriptive statistics and Kaplan-Meier (KM) methods were used for analyses. Course-specific evaluations were restricted to subjects with an end of course BM documenting morphological response and ANC/platelet values on the day of course ending BM or 1 day prior. Results: The source population contained 486 patients with the analysis cohort restricted as described above to include 313 patients in Induction I, 290 patients in Induction II, 70 patients in Reinduction I, and 34 patients in Reinduction II. This represents 707 total courses and 8933 ANC/platelet observation days, restricted from 1166 courses (371 without morphologic response and 88 lacked ANC/platelet at course end BM). Demographic covariates included age, sex, race, ethnicity, risk group, MRD, extramedullary disease, weight category, and insurance. At Induction I, MRD differed significantly by CR category for ELN and COG criteria; risk group approached but did not reach significance; and Hispanic ethnicity differed by CR category only in COG criteria. No covariates differed significantly at Reinduction I in either ELN or COG criteria. At Induction I, CR proportion differed between ELN and COG criteria: 40.9% (95% CI 35.5-46.6%) vs 69.6% (95% CI 64.2%-74.7%). At Reinduction I, CR proportion differed between ELN and COG criteria: 18.6% (95% CI 10.3-29.7%) vs 47.1% (95% CI 35.1-59.4%). Panel 1a shows median ANC at Induction I BM is <1000 (ELN) but >500 (COG) in >75% of individuals. KM analyses showed no significant differences in CR strata in ELN or COG criteria in DFS or OS at Induction I. At Reinduction I, ELN CR strata did not differ, but COG CR strata were significantly different in DFS (p = 0.0007) and OS (p = 0.0019) with CRp and CRnoANC with higher DFS than CR or CRnoANCnoPlatelet (Panel 1b). Conclusion: These real-world data suggest that ELN/COG response criteria may lead to markedly different CR rates that may impact reported response rates in clinical trials. These analyses also support COG CR response criteria in de novo pAML and CR, CRp, and CRnoANC in relapsed pAML, recognizing that the modest relapsed pAML sample size requires additional data to determine optimal response criteria.

Parent opinion on peer support programs to promote adolescent mental health

RationaleEvidence-based adolescent peer support programs for suicide prevention have shown promise in schools through increased knowledge and acceptability of help-seeking. While multiple social contacts may influence adolescent help-seeking, parents are a major factor. Thus, parent backing for peer support programs is likely to influence their impact, but little is known regarding parent perspectives on such programs. ObjectiveIn the context of a randomized clinical trial evaluating school-based depression screening, qualitative work indicated Pennsylvania parents held positive views of peer support programs. The objective of this study was to gain an understanding of parent perception of adolescent peer support programs at the national level. MethodCross-sectional US-based survey with the C.S. Mott Children’s Hospital National Poll on Children’s Health; 985 parents had a child 13–18 years-old and were eligible. Post-stratification weights were generated by survey vendor, Ipsos. Descriptive and bivariate results were calculated; logistic regression models controlled for parent demographics. ResultsParents were 55 % female, 56 % White, 81 % employed, and 52 % with an income <$100 K. Backing for peer support programs was rated as 33 % definitely, 46 % probably, 14 % unsure, and 7 % would not support; 29 % reported existing peer support programming at their teen’s school. Odds of “definitely/probably” versus “unsure/do not” support were greater among mothers versus fathers (OR 1.53 [95 % CI 1.08, 2.16]), Latinx versus White parents (OR 1.96 [95 % CI 1.15, 3.34]), and employed parents (OR 1.92 [95 % CI 1.25, 2.94]). Adding parent report of an existing program at their teen’s school to the model retained the aforementioned variables with greater support among parents exposed to this programming OR 3.20 ([95 % CI 2.01, 5.08]). Conclusions. One-third of parents favored peer support programs, especially those previously exposed to this programming. Data suggest programs may appeal to Latinx families, presenting an innovative approach to mitigate mental health disparities.

The Significance and Burden of Congenital Cytomegalovirus Infection: Interviews with Two Leading Experts

Human cytomegalovirus (CMV) is a member of the family Herpesviridae. This virus can remain dormant in the body over a long period after initial infection. Transmission of CMV occurs through direct contact with bodily fluids, such as saliva, urine, blood, semen, and breast milk, from individuals who are actively shedding the virus in these bodily fluids. CMV is extremely common and is found throughout all geographical locations and socioeconomic groups. Congenital cytomegalovirus (cCMV) infection is the most common congenital infection globally and has potentially severe consequences for infants; however, there is little awareness of cCMV infection among pregnant females, families, and healthcare professionals (HCP). For this article, EMJ conducted interviews in March 2023 with two leading experts: Christine E. Jones from the University of Southampton and University Hospital Southampton NHS Foundation Trust, UK; and Megan Pesch from the C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, USA, and the National CMV Foundation, Tampa, Florida, USA, both of whom have a wealth of experience and expertise in the management of cCMV. The experts gave valuable insights into topics such as the impact of cCMV infection on infants and their families and on public health; and screening, diagnosis, and treatment of cCMV infection. The experts also explored the potential complications of cCMV, particularly sensorineural hearing loss, the importance of prevention of maternal infection, and strategies to raise awareness of cCMV infection among HCPs and the public. In addition, Pesch provided a patient advocate perspective on the consequences of cCMV infection, sharing their experience of how cCMV has impacted their child, themself, and their family.

Variability in Clinician Awareness of Intravenous Fluid Administration in Critical Illness: A Prospective Cohort Study

AbstractIntravenous (IV) fluids are commonly administered to critically ill children, but clinicians lack effective guidance for the correct dose and duration of therapy resulting in variation of prescribing habits which harm children. It is unknown if clinicians recognize the amount of IV fluid that patients receive. We aimed to determine clinician's accuracy in the identification of the volume of IV fluids patients will receive over the next 24 hours. Prospective cohort study enrolled all patients admitted to the pediatric intensive care unit (PICU) from May to August 2021 at the University of Michigan's C.S. Mott Children's Hospital PICU. For each patient, clinicians estimated the volume of IV fluid that patients will receive in the next 24 hours. The primary outcome was accuracy of the estimation defined as predicted volume of IV fluids versus actual volume administered within 10 mL/kg or 500 mL depending on patient's weight. We tested for differences in accuracy by clinician type using chi-square tests. There were 259 patients for whom 2,295 surveys were completed by 177 clinicians. Clinicians' estimates were accurate 48.8% of the time with a median difference of 10 (1–26) mL/kg. We found that accuracy varied between clinician type: bedside nurses were most accurate at 64.3%, and attendings were least accurate at 30.5%. PICU clinicians have poor recognition of the amount of IV fluids their patients will receive in the subsequent 24-hour period. Estimate accuracy varied by clinician's role and improved over time, which may suggest opportunities for improvement.

511: SOCIAL DETERMINANTS OF HEALTH IN PEDIATRIC CRITICAL CARE: WHAT DO WE (NOT) KNOW?

1C.S. Mott Children’s Hospital at University of Michigan, Ann Arbor, MI 2C.S. Mott Children’s Hospital at University of Michigan 3CS Mott Childrens Hospital at University of Michigan, Ann Arbor, MI 4C. S. Mott Children’s Hospital, University of Michigan

Journal Digest: Post-COVID Depression; Locus Coeruleus and Alzheimer’s; CY-BOCS Reliability; and More

Journal Digest: Post-COVID Depression; Locus Coeruleus and Alzheimer’s; CY-BOCS Reliability; and More

Ingested Foreign Bodies and Toxic Materials: Who Needs to be Scoped and When?

1. Yasemin Cagil, MD* 2. Jenna Diaz, MD† 3. Seth Iskowitz, MD‡ 4. Alisa J. Muniz Crim, MD§ 1. *Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA 2. †Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Washington University School of Medicine in St Louis, St Louis, MO 3. ‡Division of Pediatric Gastroenterology, Hepatology, and Nutrition, C.S. Mott Children’s Hospital Michigan Medicine, Ann Arbor, MI 4. §Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nicklaus Children’s Hospital, Miami, FL Providers should be able to identify the signs and symptoms of foreign body and toxic material ingestion in children, select the proper diagnostic tests needed to confirm the diagnosis, and describe adequate treatment modalities for the described ingestions. After completing this article, readers should be able to: 1. Understand the common types of foreign body and toxic material ingestions. 2. Recognize the presenting symptoms of the described ingestions. 3. Recognize which patients warrant emergency endoscopic intervention. 4. Recognize which patients warrant nonemergency endoscopic intervention. 5. Recognize which patients warrant noninvasive medical management. 6. Review the role of prevention. Foreign body and toxic substance ingestions are a common reason for families to seek emergency care. Often, the pediatric patient is unable to describe the nature of the ingestion and/or the timing of the event. This can pose significant barriers to both caregivers and the medical team. Coins, button batteries, magnets, pointed and/or large objects, food, absorptive substances, alcohol, acidic and alkaline substances, detergent pods, and hydrocarbons are all frequently reported ingestions. Each ingested object or substance requires an individualized approach to management. The most common site for foreign bodies to become entrapped is in the proximal esophagus at the site of the cricopharyngeus muscle. Other common locations include the midesophagus, at the site of compression from the aortic arch, and at the lower esophageal sphincter. Most foreign bodies that are ingested by children pass spontaneously without complications; however, endoscopic removal may be necessary in some situations. Parameters that must be considered regarding the need for endoscopic removal of ingested foreign bodies include the child’s age, weight, clinical presentation, time since ingestion, type and size of the foreign body, location in the gastrointestinal tract, and underlying intestinal abnormalities. This section describes the most commonly ingested foreign bodies and their management. (1) ### Coins Coins remain the most commonly ingested …

Parent Views on School-Based Depression Screening: Findings From a National Survey

PurposeThis study explored parent views on school involvement in screening and identification of adolescent depression. MethodsThis was a cross-sectional Internet-based survey with the C.S. Mott Children’s Hospital National Poll on Children’s Health. Of 2,004 parents (63.4% response rate), 770 had a middle/high school student and were eligible for this module. Poststratification weights were generated by survey vendor Ipsos. Descriptive and bivariate results were calculated; multinomial logistic regression models controlled for parent sex, race/ethnicity, education, employment status, and school level. ResultsParent respondents were 54.8% female, 57.5% white, 64.3% above a high school education, and 79.7% employed; 76.2% were answering based on a high school student. Most parents supported school-based depression screens starting in sixth (46.7%) or seventh (15.1%) grades, although 15.9% responded no screening should be done. Among parent respondents, 93.2% wished to be informed of a positive screen. Regression analysis found parents of middle school students were 4.18 times more likely to prefer sixth versus 9th to 12th grade to start screening. ConclusionsMost parents support middle school depression screening but overwhelmingly wished to be informed of a positive result. Guidelines for maintaining adolescent confidentiality in a school-based depression screening program will require careful consideration.

Clinician Accuracy in Identifying and Predicting Organ Dysfunction in Critically Ill Children.

To determine clinician accuracy in the identification and prediction of multiple organ dysfunction syndrome. Prospective cohort study. University of Michigan's C.S. Mott Children's Hospital PICU. Patients admitted to the PICU with an anticipated PICU length of stay greater than 48 hours. None. For each patient, the clinical team (attending, fellow, resident/nurse practitioner) was surveyed regarding existing and anticipated organ dysfunction. The primary outcomes were clinicians' accuracy at identifying multiple organ dysfunction syndrome and predicting new or progressive multiple organ dysfunction syndrome, compared to the objective assessment of multiple organ dysfunction syndrome using Proulx criteria. We also measured sensitivity, specificity, negative and positive predictive values, and negative and positive likelihood ratios of clinician assessments. We tested for differences in accuracy by clinician type using chi-square tests. Clinicians rated their confidence in prediction on a 5-point Likert scale. There were 476 eligible PICU admissions, for whom 1,218 surveys were completed. Multiple organ dysfunction syndrome was present in 89 patients (18.7%) at enrollment, and new or progressive multiple organ dysfunction syndrome occurred in 39 (8.2%). Clinicians correctly identified multiple organ dysfunction syndrome with 79.9% accuracy and predicted additional organ dysfunction with 82.6% accuracy. However, the positive and negative likelihood ratios for new or progressive multiple organ dysfunction syndrome prediction were 3.0 and 0.7, respectively, indicating a weak relationship between the clinician prediction and development of new or progressive multiple organ dysfunction syndrome. The positive predictive value of new or progressive multiple organ dysfunction syndrome prediction was just 22.1%. We found no differences in accuracy by clinician type for either identification of multiple organ dysfunction syndrome (80.2% vs 78.2% vs 81.0%; p = 0.57) or prediction of new or progressive multiple organ dysfunction syndrome (84.8% vs 82.8% vs 80.3%; p = 0.26) for attendings, fellows, and residents/nurse practitioners, respectively. There was a weak correlation between the confidence and accuracy of prediction (pairwise correlation coefficient, 0.26; p < 0.001). PICU clinicians correctly identified multiple organ dysfunction syndrome and predicted new or progressive multiple organ dysfunction syndrome with 80% accuracy. However, only 8% of patients developed new or progressive multiple organ dysfunction syndrome, so accuracy was largely due to true negative predictions. The positive predictive value for new or progressive multiple organ dysfunction syndrome prediction was just 22%. Accuracy did not differ by clinician type, but was correlated with self-rated confidence and was higher for negative predictions.

Abstract 2045: Characterization of inpatient opioid use among pediatric neuroblastoma patients during dinutuximab therapy

Abstract Background: Dinutuximab is a chimeric anti-GD-2 (disialoganglioside) antibody approved for use in post-consolidation care of patients with high-risk neuroblastoma. GD-2 receptors are also expressed in cerebellar neurons, melanocytes, and peripheral sensory nerve fibers in normal human tissue. Given this pattern of expression, pain is a common and often infusion rate-limiting adverse effect, with greater than 50% of patients experiencing severe (Grade 3 or above) pain. Standard pain management for dinutuximab infusions at our center includes initiation of continuous infusion of opioid patient-controlled analgesia along with demand, loading, and boluses doses. Little to no data exist in the literature to describe opioid use in pediatric patients with acute, episodic pain. Therefore, this study aims to characterize opioid use in this setting. Methods: Data were collected retrospectively from the electronic medical record under a study protocol approved by the Institutional Review Board at the University of Michigan, C.S. Mott Children's Hospital. Patients were included in the study if they had a clinical diagnosis of metastatic or relapsed high-risk neuroblastoma, received at least one dinutuximab cycle, and were aged 2-14 at the time of admission. Daily amount of opioids, calculated as the oral morphine equivalent daily dose (MEDD), acetaminophen, and gabapentin administered were calculated. Repeated measures ANOVA was used to evaluate within-subjects changes. Results: The average age of patients was 5.7 years [range 2-14 years]. Four of eleven (36.4%) were female and 7/11 (63.6%) were male. All patients received four days of dinutuximab infusions for an average length of 11.8 hours (SD=2.0) per day. All patients received gabapentin prophylactic treatment and an average of 3387 mg (SD=1275.5). Average total MEDD across all patients was 184.7 mg (SD=137.6) during the inpatient hospitalization. Females (p=0.003) and older patients (p=0.04) had significantly increased daily MEDD as compared to their day 1 intake. All patients experienced a fever spike and received acetaminophen (2915 mg, SD=1737.8) Older patients received higher doses of acetaminophen (p=0.007) Only 1 patient met definition of a chronic opioid user and was discharged with an outpatient opioid prescription. The remaining opioid-naïve patients were discontinued on opioid treatment at the time of discharge. Conclusions: Pediatric patients on dinutuximab therapy received a high MEDD parenteral opioids dose alongside adjunctive analgesics. Future studies are needed to determine opioid requirement trends across gender, age, and cycles in a larger cohort of patients, as well as to determine the risk of chronic opioid use in this patient population. Citation Format: Jola Mehmeti, Jae Eun Choi, Ian Wolfe, Juan Cata, Rajen Mody. Characterization of inpatient opioid use among pediatric neuroblastoma patients during dinutuximab therapy [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2045.

Vascular Access in Children With Congenital Heart Defects.

* Abbreviations: CVAD — : central venous access device miniMAGIC — : Michigan Appropriateness Guide for Intravenous Catheters in pediatrics VAD — : vascular access device Vascular access in pediatric cardiac patients is an inherently complex topic. Many clinicians struggle to understand the “plumbing,” let alone the implications that particular cardiovascular anatomic and physiologic derangements and our strategies of palliation have for children, both for the present and the future. Each choice a clinician makes regarding where and how to place a vascular access device (VAD), the length and diameter of the catheter, the surveillance and maintenance practices for the catheter, the duration the catheter is left indwelling, the types of therapies administered through the catheter, the blood sampled through the catheter, and the decision to remove the catheter can have major implications for a child’s future candidacy for additional catheterization and surgery. Simultaneously accounting for all of these factors can result in an incomprehensible morass. Through the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC), we have employed the use of an expert panel and the RAND Corporation and University of California, Los Angeles appropriateness methodology (which is similar to the approach that was used … Address correspondence to Ranjit Aiyagari, MD, Division of Pediatric Cardiology, C.S. Mott Children’s Hospital, 1540 E Hospital Dr, Ann Arbor, MI 48109-4204. E-mail: ranjita{at}umich.edu

How do you define recovery? A qualitative study of patients with eating disorders, their parents, and clinicians.

Recovery from an eating disorder (ED) may be defined differently by different stakeholders. We set out to understand the definition of ED recovery from the perspective of patients, their parents, and clinicians. We recruited patients with EDs (n = 24, ages 12-23 years) representing different diagnoses (anorexia nervosa n = 17, bulimia nervosa n = 4, binge-ED n = 2, avoidant/restrictive food intake disorder n = 1), along with their parents (n = 20), dietitians (n = 11), therapists (n = 14), and primary care providers (n = 9) from three sites: Boston Children's Hospital, University of Michigan C. S. Mott Children's Hospital, and Penn State Hershey Children's Hospital. In-depth, semi-structured, qualitative interviews explored participants' definitions of recovery. Interviews were analyzed using inductive data-driven thematic analysis. Statistical analyses followed to examine the distribution within each theme by respondent type. Qualitative analysis resulted in the emergence of four overarching themes of ED recovery: (a) psychological well-being, (b) eating-related behaviors/attitudes, (c) physical markers, and (d) self-acceptance of body image. Endorsement of themes two and four did not significantly differ between patients, parents, and clinicians. Clinicians were significantly more likely to endorse theme one (χ2 = 9.90, df = 2, p = .007, φc = 0.356) and theme three (χ2 = 6.42, df = 2, p = .04, φc = 0.287) than patients and parents. Our study demonstrates overwhelming support for psychological markers as indicators of ED recovery by all three groups. Clinicians should remain open to additional markers of recovery such as body acceptance and eating-related behaviors/emotions that may be of critical importance to patients and their caregivers.

Predicting Acute Graft-Versus-Host Disease Using Machine Learning and Longitudinal Vital Sign Data From Electronic Health Records.

PURPOSEAcute graft-versus-host disease (aGVHD) remains a significant complication of allogeneic hematopoietic cell transplantation (HCT) and limits its broader application. The ability to predict grade II to IV aGVHD could potentially mitigate morbidity and mortality. To date, researchers have focused on using snapshots of a patient (eg, biomarkers at a single time point) to predict aGVHD onset. We hypothesized that longitudinal data collected and stored in electronic health records (EHRs) could distinguish patients at high risk of developing aGVHD from those at low risk.PATIENTS AND METHODSThe study included a cohort of 324 patients undergoing allogeneic HCT at the University of Michigan C.S. Mott Children’s Hospital during 2014 to 2017. Using EHR data, specifically vital sign measurements collected within the first 10 days of transplantation, we built a predictive model using penalized logistic regression for identifying patients at risk for grade II to IV aGVHD. We compared the proposed model with a baseline model trained only on patient and donor characteristics collected at the time of transplantation and performed an analysis of the importance of different input features.RESULTSThe proposed model outperformed the baseline model, with an area under the receiver operating characteristic curve of 0.659 versus 0.512 (P = .019). The feature importance analysis showed that the learned model relied most on temperature and systolic blood pressure, and temporal trends (eg, increasing or decreasing) were more important than the average values.CONCLUSIONLeveraging readily available clinical data from EHRs, we developed a machine-learning model for aGVHD prediction in patients undergoing HCT. Continuous monitoring of vital signs, such as temperature, could potentially help clinicians more accurately identify patients at high risk for aGVHD.

Sociodemographic Factors Associated With Adherence to Referrals From the Pediatric Emergency Department.

Outpatient referrals constitute a critical component of emergency medical care. However, barriers to care after emergency department (ED) visits have not been investigated thoroughly. The purpose of this study was to determine the impact of sociodemographic variables on referral attendance after ED visits. A retrospective cohort study was designed. Patients aged 0-17years who visited the C.S. Mott Children's Hospital ED in 2016 and received a referral were included. Multiple referrals for 1 patient were counted as independent encounters for statistical analysis. Chart review was performed on 6120 pediatric ED encounters, producing a total of 822 referrals to University of Michigan Health System outpatient clinics. Referral attendance did not differ by race, ethnicity, language, or religion. Older age was associated with decreased attendance at referrals (p=0.043). Patients who were black and female (p=0.019), patients with public health insurance (p=0.004), and patients residing in areas with either high rates of unemployment (p=0.003), or lower high school education rates (p=0.006) demonstrated decreased attendance. Patients referred to pediatric neurology had lower attendance rates (p<0.001), and those referred to pediatric orthopedic surgery attended referrals more often (p=0.006). This study provides an overview of the impact of sociodemographic and departmental factors on attendance at outpatient follow-up referrals. Significant disparities exist with respect to referral attendance after emergency medical care. Informed resource allocation may be utilized to improve care for these at-risk patient populations.

3-D printing takes on the body

One in every 2,000 children is born with tracheobronchomalacia, a life-threatening weakness of the walls of the trachea that can collapse the airway, making it difficult or impossible to breathe. In 2012, Glenn Green, a pediatric otolaryngologist at C.S. Mott Children’s Hospital in Ann Arbor, Michigan, was treating five people—four babies and one adolescent—with the condition. He teamed up with Scott Hollister, a professor of biomedical engineering at the University of Michigan, to create splints that would support the trachea. Guided by computed tomography scans of the patients, the pair 3-D printed splints out of the ductile and bioresorbable polymer polycaprolactone for the babies and out of high-performance polyether ketone ketone (PEKK) for the teenager. The splints allowed the children to breathe normally until their own tissues grew strong enough for them to do so unassisted. To date, some 60 splints have been placed in 30 people. Green, who sees

1124. Impact of a Best Practice Advisory for Pediatric Patients with Staphylococcus aureus Bloodstream Infection

BackgroundInfectious diseases (ID) consultation and use of optimal antibiotic therapy have been shown to improve outcomes of patients with Staphylococcus aureus bloodstream infection (SA-BSI). We investigated the ability of an electronic medical record (EMR)-based best practice advisory (BPA) to enhance adherence to these practices for pediatric patients with SA-BSI.MethodsAn EMR-based BPA for SA-BSI (Figure 1) was implemented on 8/1/2017, recommending ID consultation and optimal therapy based on mecA gene rapid testing (vancomycin if mecA-positive; cefazolin or nafcillin if mecA-negative). We conducted a quasi-experimental pre/post study to evaluate impact of the BPA. Patients <21 years old admitted to C.S. Mott Children’s Hospital with SA-BSI during the pre- (1/2015 – 7/2017) and post-intervention (8/2017 – December 2018) periods were included. Demographic and clinical data were collected via chart review. Receipt of ID consult and optimal therapy before and after intervention were compared using interrupted time series (ITS) analysis with segmented regression. Time to optimal therapy was compared with segmented Cox regression.ResultsWe included 99 SA-BSI episodes (70.7% pre-intervention and 29.3% post-intervention). Pre-intervention, 68.6% of patients received an ID consult compared with 93.1% post-intervention, but this was not significant with ITS analysis (Figure 2). The proportion of patients receiving optimal therapy did not significantly increase following the intervention, but time to optimal therapy significantly decreased (Figure 3). The median time to optimal therapy decreased from 26.1 hours to 5.5 hours. Cox regression showed both an immediate decrease in time to optimal therapy (HR 3.9, P = 0.009), followed by a continued decrease over time.ConclusionFollowing implementation of a novel EMR-based intervention, ID consultation for SA-BSI increased, although this was not statistically significant due to a pre-existing trend of increasing ID consults over time. Implementation of the BPA was associated with a significant decrease in time to optimal therapy, likely due to a combination of increasing ID consultation and antibiotic guidance provided by the BPA. Disclosures All authors: No reported disclosures

Congenital Portosystemic Shunts in Children: Associations, Complications, and Outcomes.

Congenital portosystemic shunt (CPSS) is a rare malformation in which splanchnic venous flow bypasses the liver. CPSS is associated with other congenital anomalies and syndromes and can be associated with life-threatening complications. CPSS and their management remain underreported in the literature. Here, we review the clinical characteristics, management, and outcomes of a cohort of children and young adults with CPSS from two pediatric centers. Cases of CPSS from Cincinnati Children's Hospital Medical Center and C.S. Mott Children's Hospital were reviewed to define CPSS anatomy, associated anomalies, complications, interventions, and outcomes. The imaging features and histopathology of liver lesions were characterized in detail. A total of 11 cases were identified. Median age was 10years (range 0-26); 8 (73%) cases were female. Associated anomalies included six patients with heterotaxy (55%), five patients with congenital heart disease (45%), three patients with Turner syndrome (27%), and two patients with omphalocele, exstrophy, imperforate anus, spinal defects (OEIS) complex (18%). Eight (73%) cases had hyperammonemia ± encephalopathy. A 4-month-old presented with hepatopulmonary syndrome, and 12-year-old presented with pulmonary hypertension. Eight patients (73%) had liver lesions including five with premalignant adenomas and three with well-differentiated hepatocellular carcinoma (HCC). Four children underwent successful CPSS occlusion/ligation. Three children underwent liver transplant (2) or resection (1) for HCC without recurrence at extended follow-up. CPSS is associated with multiple anomalies (heterotaxy, congenital heart disease) and syndromes (Turner syndrome). CPSS liver lesions should be very carefully evaluated due to risk of premalignant adenomas and HCC. Serious complications of CPSS can occur at a young age but can be managed endovascularly or with open surgery.

A Multidisciplinary Approach to Equipment Use in Pediatric Patient Mobilization.

Research has shown that patients who are mechanically ventilated or immobile for greater than 7 days are at increased risk for deconditioning and muscle atrophy. Immobility impacts length of stay as well as patients' ability to return to their prior level of function. As part of the safe patient-handling initiative created at Michigan Medicine, a special team of nurses and therapists was assembled to adapt an adult mobility framework for the pediatric population. The pediatric mobility model determines each patient's specific mobility "phase" based on detailed criteria. Clinical staff can then implement strategies aimed at preventing deconditioning and hospital-acquired weakness. At C.S. Mott Children's Hospital, a multidisciplinary team is available to support this pediatric mobility model. Specific equipment utilized during the different phases of mobility has been reviewed and discussed in this article.

Functional Status Change Among Children With Extracorporeal Membrane Oxygenation to Support Cardiopulmonary Resuscitation in a Pediatric Cardiac ICU: A Single Institution Report.

The purpose of this study is to describe the functional status of survivors from extracorporeal cardiopulmonary resuscitation instituted during in-hospital cardiac arrest using the Functional Status Scale. We aimed to determine risk factors leading to the development of new morbidity and unfavorable functional outcomes. This was a single-center retrospective chart review abstracting patient characteristics/demographic data, duration of cardiopulmonary resuscitation, duration of extracorporeal membrane oxygenation support, as well as maximum lactate levels within 2 hours before and after extracorporeal cardiopulmonary resuscitation. Cardiac arrest was defined as the administration of chest compressions for a nonperfusing cardiac rhythm. Extracorporeal cardiopulmonary resuscitation was defined by instituting extracorporeal membrane oxygenation during active chest compressions. Functional Status Scale scores were calculated at admission and on hospital discharge for patients who survived. Patients admitted in the pediatric cardiac ICU at C.S. Mott Children's Hospital from January 1, 2005, to December 31, 2015. Children less than 18 years who underwent extracorporeal cardiopulmonary resuscitation. Not applicable. Of 608 extracorporeal membrane oxygenation events during the study period, 80 were extracorporeal cardiopulmonary resuscitation (14%). There were 40 female patients (50%). Median age was 40 days (interquartile range, 9-342 d). Survival to hospital discharge was 48% (38/80). Median Functional Status Scale score at admission was 6 (interquartile range, 6-6) and at hospital discharge 9 (interquartile range, 8-11). Out of 38 survivors, 19 (50%) had a change of Functional Status Scale score greater than or equal to 3, that is consistent with new morbidity, and 26 (68%) had favorable functional outcomes with a change in Functional Status Scale score of less than 5. This is the first extracorporeal cardiopulmonary resuscitation report to examine changes in Functional Status Scale from admission (baseline) to discharge as a measure of overall functional outcome. Half of surviving patients (19/38) had new morbidity, while 68% (26/38) had favorable outcomes. Lactate levels, duration of cardiopulmonary resuscitation, and duration of extracorporeal membrane oxygenation were not found to be risk factors for the development of new morbidity and poor functional outcomes. Functional Status Scale may be used as a metric to monitor improvement of extracorporeal cardiopulmonary resuscitation outcomes and help guide research initiatives to decrease morbidity in this patient population.