Pediatric Acute Care Setting Research Articles

Impact of Antibiotic Stewardship on Treatment of Hospitalized Children with Skin and Soft-Tissue Infections

Background: Skin and soft-tissue infections (SSTIs) are common infectious syndromes in children. Overusing broad-spectrum antibiotics has contributed to rising antibiotic resistance, complicating treatment outcomes. To address this issue, antimicrobial stewardship programs (ASPs) have been implemented to optimize antibiotic use. This study evaluated the impact of a multifaceted ASP on antibiotic prescribing practices for SSTIs in a pediatric acute care setting over eight years. Methods: We conducted a quasi-experimental study at the Pediatric Acute Care Unit of the Padua University Hospital, including children admitted with SSTIs from October 2014 to September 2022, to evaluate the impact of a multifaceted ASP implemented in October 2015. The study was divided into three periods: pre-implementation (October 2014–September 2015), post-implementation (October 2015–March 2020), and COVID-19 (April 2020–August 2022). Data on antibiotic prescriptions and microbiological results were collected and analyzed. Results: The implementation of the ASP led to a significant reduction in the use of broad-spectrum antibiotics, particularly third-generation cephalosporins (from 40.4% to 9.8%) and glycopeptides (from 21.1% to 1.6%). There was a notable increase in the prescription of Access antibiotics, from 30% in the pre-implementation to over 60% in the post-implementation and 80% during COVID-19. No increase in the hospital length of stay was observed. Microbiological results showed no significant changes in bacterial profiles over time. Conclusions: The use of the ASP effectively improved antibiotic prescribing practices, reducing reliance on broad-spectrum antibiotics even during the COVID-19 pandemic. These findings highlight the value of ongoing stewardship efforts and suggest the need for similar programs in ambulatory settings to further address antibiotic resistance.

Risk Factors for Deterioration Events in the Pediatric Acute Care Setting.

Rapid response system (RRS) activations resulting in emergency transfers (ETs) and codes outside the ICU are associated with increased mortality and length of stay. We aimed to evaluate the patient and care team characteristics of RRS activations resulting in ETs and codes outside the ICU (together classified as "deterioration events") versus those that did not result in a deterioration event. For each RRS activation at our institution from 2019 to 2021, data were gathered on patient demographics and medical diagnoses, care team and treatment factors, and ICU transfer. Descriptive statistics, bivariate analyses, and multivariable logistic regression using a backward elimination model selection method were performed to assess potential risk factors for deterioration events. Over the 3-year period, 1765 RRS activations were identified. Fifty-three (3%) activations were deemed acute care codes, 64 (4%) were noncode ETs, 921 (52%) resulted in nonemergent transfers to an ICU, and 727 (41%) patients remained in an acute care unit. In a multivariable model, any complex chronic condition (adjusted odds ratio, 6.26; 95% confidence interval, 2.83-16.60) and hematology/oncology service (adjusted odds ratio, 2.19; 95% confidence interval, 1.28-3.74) were independent risk factors for a deterioration event. Patients with medical complexity and patients on the hematology/oncology service had a higher risk of deterioration events than other patients with RRS activations. Further analyzing how our hospital evaluates and treats these specific patient populations is critical as we develop targeted interventions to reduce deterioration events.

How to follow the guidelines, when the appropriate fluid is missing?

Intravenous maintenance fluid therapy (IV-MFT) is probably the most prescribed drug in paediatric hospital care. Recently paediatric societies have produced evidence-based practice guidelines that recommend the use of balanced isotonic fluid when prescribing IV-MFT in both acute and critical paediatric care. Unfortunately, the applicability of these guidelines could be called into question when a ready-to-use glucose-containing balanced isotonic fluid is not available. The main objective of this study was to describe the availability of glucose-containing balanced isotonic fluids in European and Middle Eastern paediatric acute and critical care settings. This work is an ancillary study of the survey dedicated to IV-MFT practices in the paediatric acute and critical care settings in Europe and Middle East, a cross-sectional electronic 27-item survey, emailed in April-May 2021 to paediatric critical care physicians across 34 European and Middle East countries. The survey was developed by an expert multi-professional panel within the European Society of Peadiatric and Neonatal Intensive Care (ESPNIC). Balanced isotonic fluid with glucose 5% was available for only 32/153 (21%) responders. Balanced isotonic fluid with glucose 5% was consistently available in the UK (90%) but not available in France, Greece, The Netherlands and Turkey. Conclusion: Ready-to-use isotonic balanced IV solutions containing glucose in sufficient amount exist but are inconsistently available throughout Europe. National and European Medication Safety Incentives should guarantee the availability of the most appropriate and safest IV-MFT solution for all children. What is Known: • Intravenous maintenance fluid therapy (IV-MFT) is probably the most prescribed drug in paediatric hospital care. • Balanced isotonic fluid is recommended when prescribing IV-MFT in both acute and critical paediatric care. What is New: • Balanced isotonic fluid with glucose 5% is available for less than 25% of the prescribers in Europe and the Middle East.Availability of balanced isotonic fluid with glucose 5% varies from one country to another but can also be inconsistent within the same country. • Clinicians who have access to a ready-to-use balanced isotonic fluid with glucose 5% are more likely to consider its use than clinicians who do not have access to such an IV solution.

Parental supporter during pediatric resuscitation: Qualitative exploration of caregivers' and healthcare professionals' experiences and perceptions

BackgroundChild resuscitation is a critical and stressful time for family caregivers and healthcare professionals. The aim of this study was to explore caregivers’ and healthcare professionals’ experiences and perceptions of a parental supporter during pediatric cardiopulmonary resuscitation to provide guidance to healthcare professionals on supporting parents and other family caregivers during resuscitation. MethodsThis study used an exploratory descriptive qualitative approach. The setting was two large referral pediatric governmental hospitals. Participants were 17 caregivers who had experienced their child’s resuscitation, and 13 healthcare professionals who served on resuscitation teams in emergency rooms or intensive care wards. Semi-structured, in-depth interviews were conducted and data were analyzed using thematic analysis. COREQ guidelines were followed. ResultsParticipants shared their experiences and perceptions of a parental supporter during pediatric resuscitation in three themes: 1) Requirement for the presence of a parental supporter, 2) Expectations of the parental supporter, and 3) Characteristics of the parental supporter. ConclusionsStudy findings highlight the need for a parental supporter during pediatric resuscitation; however, there is no defined parental supporter role in current guiding policies due to limited research on this role. More research on the parental supporter role is needed so effective policies and protocols can be developed to enhance family-centered care practices in pediatric emergency and acute care settings.

22.2 Aggression/Acute Agitation: Identification and Management in Pediatric Acute Care Settings

22.2 Aggression/Acute Agitation: Identification and Management in Pediatric Acute Care Settings

Development of a Novel Massage Therapy Outcome Measure for Children and Young Adults Receiving Hematopoietic Cell Transplant.

Children receiving hematopoietic stem cell transplantation (HCT) often experience an unfortunate sequalae of negative effects including pain, deconditioning, and anxiety. Massage therapy (MT) has demonstrated effective non-pharmacological management of fatigue, pain, and anxiety in patients undergoing cancer treatment. Existing studies have been limited by the lack of available MT-specific outcome measures to track responses to interventions. This study aimed to describe the creation of a novel MT-specific outcome measure to be utilized in the pediatric acute-care setting and establish construct validity for this measure to assess clinical effectiveness of MT interventions. An oncology ward at a large pediatric tertiary medical center in the United States. A total of 58 children and young adults undergoing HCT. Retrospective Cohort Study. A panel of massage therapists created a novel outcome measure, OMPREP, for use in MT sessions and performed a literature review to ensure face validity of the tool. This outcome measure was administered to patients and data were collected retrospectively to assess construct validity. A total of 1,333 MT sessions were completed (80.7% completion rate) with the novel OMPREP outcome measure utilized on 100% of visits. Mean engagement (p<.001), response (p<.001), and pain (p<.001) scores were all significantly greater at evaluation and discharge compared to the lowest observed scores post-HCT. The novel MT-specific outcome measure, OMPREP, was feasible and demonstrated construct validity when implemented in a pediatric acute-care setting by massage therapists. This new tool may offer a quantitative measure of MT-interventions and assist in tracking patient outcomes.

Family engagement in paediatric acute care settings: A realist review.

To create a programme theory of family engagement in paediatric acute care to explicate the relationships between contexts and mechanisms of family engagement that align with family, direct care providers and healthcare organization outcomes. Realist review and synthesis. PubMed, CINAHL, PsycINFO and Web of Science searches for the 2.5-year period (July 2019-December 2021) following our 2021 scoping review. Following methods described by Pawson and Rycroft-Malone, we defined the scope of the review, searched for and appraised the evidence, extracted and synthesized study findings and developed a supporting narrative of our results. Of 316 initial citations, 101 were included in our synthesis of the final programme theory. Contexts included family and direct care provider individualism, and the organizational care philosophy and environment. Mechanisms were family presence, family enactment of a role in the child's care, direct care providers facilitating a family role in the child's care, unit/organizational promotion of a family role, relationship building and mutually beneficial partnerships. Outcomes were largely family-focussed, with a paucity of organizational outcomes studied. We identified four context-mechanism-outcome configurations. This realist review uncovered underlying contexts and mechanisms between patients, direct care providers and organizations in the family engagement process and key components of a mutually beneficial partnership. Given that successful family engagement requires direct care provider and organizational support, future research should expand beyond family outcomes to include direct care providers, particularly nurses and healthcare organization outcomes. The final programme theory of family engagement in paediatric acute care provides a roadmap for clinicians to develop complex interventions to engage families and evaluate their impact. The components of our final programme theory reflect family engagement concepts that have been evolving for decades. The team conducting this review included members from the practice setting (JT & KG). In the future, as we and others use this model in practice, we will seek input for refinement from clinicians, patients and caregivers.

Patient-Reported Outcome Measure Use by Acute Care Pediatric Physical Therapists

Purpose: To describe the current use of and perceived benefits and barriers to using patient-reported outcome measures (PROMs) by pediatric physical therapists (PTs) in the acute care setting and to explore demographic factors that may explain the use of PROMs. Methods: An electronic survey was distributed to PTs who work in a pediatric acute care setting. Descriptive statistics were used to assess the frequency of PROM use, identify differences in PROM use based on demographic factors, and evaluate the likelihood of various benefits and barriers. Open-ended survey responses were analyzed inductively to identify common themes. Results: The survey was completed by a convenience sample of 92 pediatric acute care PTs (30% response rate). Half of the respondents (n = 46; 50%) reported “rarely” or “never” using PROMs, while only 4.3% (n = 4) reported “always” using PROMs. No significant differences were found in the frequency of PROM between years of experience, entry-level degree, clinical specialization, or other demographic factors. Participants were “somewhat” or “extremely likely” to use the rate of perceived exertion (71%), the Ages and Stages Questionnaire (24%), and the Pediatric Quality of Life Inventory (17%). The primary facilitator was improving communication with patients (68%), while the main barrier was lack of availability (57%). Thematic analysis of open-ended responses indicated that the benefits of using PROMs include improving communication, providing objective data, and measuring progress. Barriers identified include inadequate resources, lack of time, and irrelevance to clinical practice. Conclusion: Many pediatric acute care PTs underutilize PROMs, with reported barriers of limited access and lack of time hindering implementation within the pediatric acute care setting. Survey respondents reported the desire to measure health-related quality of life and participation, which may be feasible through future quality improvement or knowledge translation initiatives.

Perceptions of Patient-Reported Outcome Measures in Acute Care Pediatric Physical Therapy

Purpose: To explore the perceptions and experiences of acute care pediatric physical therapists (PTs) regarding the use of patient-reported outcome measures (PROMs) and to understand the influence of PROMs on clinical decision-making and the plan of care. Methods: Thirteen acute care pediatric PTs participated in individual semistructured interviews using a qualitative phenomenological approach. Interview questions focused on how PROMs influence clinical practice and decision-making. Interviews also explored scenarios where using PROMs positively or negatively impacted patient and caregiver interactions. Researchers analyzed the interview transcripts using an inductive process to generate codes and resultant themes. Results: Participants described their experiences using PROMs in pediatric acute care, and 4 themes emerged: (1) PROMs can be difficult to implement in pediatric acute care, (2) PROMs can benefit pediatric acute care practice, (3) PROMs can improve service delivery and family-centered care, and (4) ideal PROM use in future practice. The Theoretical Domains Framework (TDF) was used to categorize positive and negative factors related to implementing evidence-based guidelines in the pediatric acute care setting. Conclusions: Acute care pediatric PTs report benefits and barriers to using PROMs with children and caregivers in the hospital setting. Findings support the need for future knowledge translation initiatives to facilitate the use of PROMs in pediatric acute care.

A case series evaluation of comprehensive drug testing in the pediatric acute care setting

IntroductionDrug testing typically follows a one-size-fits-all approach that is inadequate in some clinical scenarios, such as child maltreatment, neglect, and unintentional drug exposure. Results from immunoassay-based testing, which are non-specific, insensitive, and far from comprehensive, can lead to unintended consequences for children and their families. ObjectivesThe objective of this retrospective case series study is to evaluate the utility of real-time (0–1 day) comprehensive drug testing as an alternative to immunoassay-based testing in the pediatric acute care setting. MethodsComprehensive drug testing results obtained by mass spectrometry testing and associated medical data for all pediatric cases (0–12 years) at one institution from 2019 to 2022 were included in the analysis. The final case series (n = 7) included all cases from patients <3 years with comprehensive drug testing results that were inconsistent with medication history and/or toxicology results by immunoassay. ResultsComprehensive drug testing by mass spectrometry was ordered for 174 urine and blood samples representing 97 patients (0–12 years) from 2019 to 2022. Of these, 76 cases were from patients <3 years old; results were consistent with medication history and confirmatory for immunoassay results (n = 34), consistent with medication history (n = 14), confirmatory for immunoassay results (n = 10), negative (n = 9), or medical history was incomplete (n = 2). The remaining 7 cases were included in the final case series. ConclusionsThe cases highlight the value of real-time comprehensive drug testing in acute pediatric cases. Testing results can rule out toxic exposure from the diagnostic differential when negative, and lead to appropriate medical and social interventions when positive.

Different Pediatric Acute Care Settings Influence Bronchiolitis Management: A 10-Year Retrospective Study

Bronchiolitis is the main cause of hospitalization in infants. Diagnosis is clinical, and treatment is based on hydration and oxygen therapy. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. This retrospective study aimed to evaluate whether the setting of bronchiolitis care influences diagnostic and therapeutic choices. The management of 3201 infants, referred to our Italian Tertiary Care Center for bronchiolitis between 2010 and 2020, was analyzed by comparing children discharged from the pediatric emergency department (PEDd group) undergoing short-stay observation (SSO group) and hospitalization. Antibiotic use in PEDd, SSO, and ward was 59.3% vs. 51.6% vs. 49.7%, respectively (p < 0.001); inhaled salbutamol was mainly administered in PEDd and during SSO (76.1% and 82.2% vs. 38.3% in ward; p < 0.001); the use of corticosteroids was higher during SSO and hospitalization (59.6% and 49.1% vs. 39.0% in PEDd; p < 0.001); inhaled adrenaline was administered mostly in hospitalized infants (53.5% vs. 2.5% in SSO and 0.2% in PEDd; p < 0.001); chest X-ray use in PEDd, SSO, and ward was 30.3% vs. 49.0% vs. 70.5%, respectively (p < 0.001). In a multivariate analysis, undergoing SSO was found to be an independent risk factor for the use of systemic corticosteroid and salbutamol; being discharged at home was found to be a risk factor for antibiotic prescription; undergoing SSO and hospitalization resulted as independent risk factors for the use of CXR. Our study highlights that different pediatric acute care settings could influence the management of bronchiolitis. Factors influencing practice may include a high turnover of PED medical staff, personal reassurance, and parental pressure.

Nurses’ Perceptions of a Novel Rooming-in Program for Infants With Critical Congenital Heart Disease

The transition to home for infants who require complex care can be overwhelming for caregivers. Infants with critical congenital heart disease (CCHD) require advanced care management, so their caregivers must acquire extensive training before the infants are discharged home. Rooming-in programs have improved patient outcomes in other settings, such as the postpartum period. However, little research has examined a rooming-in program in a pediatric cardiac acute care setting. To describe nurses' perceptions of a novel rooming-in program implemented in a pediatric cardiac acute care unit. A qualitative descriptive research design was used to describe nurses' perceptions of the rooming-in program for infants with CCHD. Three focus groups were conducted with a convenience sample of 13 registered nurses who cared for infants with CCHD during the rooming-in program. Four trained independent coders performed qualitative thematic analysis. Nurses provided critical insight into the rooming-in program. Three themes were identified: improved nursing and family outcomes, leading the way through collaboration, and room for improvement. Infants with CCHD have complex needs, and caregivers must acquire advanced skills to adequately care for these infants. This study is the first to explore nurses' perceptions of a rooming-in program for infants with CCHD. The findings could improve rooming-in programs in the pediatric acute care setting, which can translate to better patient outcomes.

Point-of-care ultrasound needs assessment in a paediatric acute care setting in Malawi.

To describe the use of point-of-care ultrasound (POCUS) in an acute-care paediatric setting in Malawi, including clinical indications, types of examinations and frequency of positive findings. Retrospective, cross-sectional study of a convenience sample of POCUS examinations performed in one tertiary referral hospital in Lilongwe, Malawi over 1 year. POCUS examinations were performed by Paediatric Emergency Medicine physician consultants as part of routine clinical practice and at the request of local clinicians. Images were saved along with the clinical indication and physician interpretation for quality review. Ultrasounds performed by the radiology department and those examinations that were technically faulty, missing clinical application or interpretation were excluded. In total, 225 ultrasounds of 142 patients were analysed. The most common clinical indications for which examinations were completed were respiratory distress (23%), oedema (11.7%) and shock/arrest (6.2%). The most common examinations performed were cardiac (41.8%) and lung (15.1%), focused assessment with sonography in trauma (FAST; 12.9%) and ultrasound-guided procedural examinations (9.8%). Pathology was identified in 68% of non-procedural examinations. Cardiac examinations demonstrated significant pathology, including reduced cardiac function (12.8%), gross cardiac structural abnormality (11.8%) and pericardial effusion (10.3%). POCUS was used for both clinical decision-making and procedural guidance, and a significant number of POCUS examinations yielded positive findings. Thus, we propose that cardiopulmonary, FAST and procedural examinations should be considered in future for the POCUS curriculum in this setting.

Improving research personnel's hand hygiene adherence in the pediatric acute care setting during the COVID-19 pandemic: a quality improvement initiative.

Hand hygiene is critical in preventing the spread of healthcare-associated infections. Routine hand hygiene surveillance and education are common for clinical staff in pediatric acute care settings. However, nonclinical staff, including research personnel, are often excluded from these programs and therefore represent a gap in ongoing infection control efforts. This project aimed to evaluate the impact of evidence-based interventions on improving hand hygiene adherence among research personnel in the pediatric emergency department to meet provincial targets set for clinical staff. We used a Plan-Do-Study-Act approach to carry out a peer-driven, multimodal hand hygiene improvement strategy involving education, surveillance, and feedback targeted to research assistants working in a pediatric emergency department. Two anonymous peer evaluators observed hand hygiene practices in several specific instances (eg, before/after patient interactions) and determined adherence a priori. In an open sample of clinical research assistants (Ntotal = 22), hand hygiene adherence increased from 12.5% to 89.1% over 11 months. Increases in adherence were particularly notable before entering the patient environment compared to exiting. Hand hygiene interventions targeting research personnel show potential success in acute care. Further quality improvement initiatives in larger research personnel samples must robustly evaluate the framework's effectiveness.

Innovative Strategies to Promote Safe Nurse Staffing in the Maternity, Neonatal, and Pediatric Acute Care Setting.

Innovative Strategies to Promote Safe Nurse Staffing in the Maternity, Neonatal, and Pediatric Acute Care Setting.

Distinct Characteristics and Chronology of Amoxicillin-Associated Reactions in Pediatric Acute Care Settings

Amoxicillin-associated reactions (AARs) in children presenting as rashes are common, and recent data suggest that >90% tolerate amoxicillin on re-exposure. However, additional data would help pediatricians and allergists gain confidence in referring and testing children who experienced systemic symptoms perceived as "worrisome," thus leading to urgent medical evaluations. By characterizing the entire spectrum of AAR symptoms in pediatric patients presenting to emergency department (ED)/urgent care (UC) settings, we sought to increase our diagnostic acumen to guide subsequent allergy evaluations. To fully characterize clinical features of rash and systemic symptoms in children presenting to the ED/UC with AARs. A retrospective chart review of children seen in the ED/UC from July 1, 2015, to June 30, 2017, was conducted. Clinical features, chronology, and seasonality were detailed, and cases were classified into 3 previously described AAR phenotypes: maculopapular exanthem (MPE), urticaria, and serum sickness-like reactions (SSLRs), if they experienced joint symptoms. Children (n= 668; median age: 1.8 years) presented to the ED/UC with urticaria (44%), MPE (36%), and SSLRs (11%) typically on days 7 to 10 of amoxicillin. Although children with SSLRs were more frequently treated with corticosteroids (28%, P < .0001) and exhibited higher rates of "worrisome" features (fever, angioedema, or gastrointestinal symptoms; 73%, P < .0001), delayed-onset systemic symptoms were identified frequently in all 3 groups. ED/UC reutilization was unexpectedly high with 66 children (10%) returning to the ED/UC for re-evaluation. "Worrisome" symptoms are common in children presenting to the ED/UC with AARs. Future studies are needed to determine the impact on subsequent referral and allergy testing.

Intravenous maintenance fluid therapy practice in the pediatric acute and critical care settings: a European and Middle Eastern survey.

The ideal fluid for intravenous maintenance fluid therapy (IV-MFT) in acutely and critically ill children is controversial, and evidence-based clinical practice guidelines are lacking and current prescribing practices remain unknown. We aimed to describe the current practices in prescribing IV-MFT in the context of acute and critically ill children with regard to the amount, tonicity, composition, use of balanced fluids, and prescribing strategies in various clinical contexts. A cross-sectional electronic 27-item survey was emailed in April-May 2021 to pediatric critical care physicians across European and Middle East countries. The survey instrument was developed by an expert multi-professional panel within the European Society of Pediatric and Neonatal Intensive Care (ESPNIC). A total of 154 respondents from 35 European and Middle East countries participated (response rate 64%). Respondents were physicians in charge of acute or critically ill children. All respondents indicated they routinely use a predefined formula to prescribe the amount of IV-MFT and considered fluid balance monitoring very important in the management of acute and critically ill children. The use of balanced solution was preferred if there were altered serum sodium and chloride levels or metabolic acidosis. Just under half (42%, 65/153) of respondents believed balanced solutions should always be used. Respondents considered the use of isotonic IV solutions as important for acute and critically ill children. In terms of the indication and the composition of IV-MFT prescribed, responses were heterogeneous among centers. Almost 70% (107/154) respondents believed there was a gap between current practice and what they considered ideal IV-MFT due to a lack of guidelines and inadequate training of healthcare professionals. Conclusions: Our study showed considerable variability in clinical prescribing practice of IV-MFT in acute pediatric settings across Europe and the Middle East. There is an urgent need to develop evidence-based guidelines for IV-MFT prescription in acute and critically ill children. What is Known: •The administration of maintenance intravenous fluid therapy is a standard of care for a lot of hospitalized children •Maintenance intravenous fluid therapy prescriptions are often based on Holliday and Segar's historical guidelines even if this practice has been associated with several complications. What is New: •This study provided information on the prescribing practice regarding fluid restriction, fluid tonicity, and balance. •This study showed considerable variability in clinical prescribing practice of intravenous maintenance fluid therapy across Europe and the Middle East.

Parents’ and healthcare professionals’ experiences and perceptions of parental readiness for resuscitation in Iranian paediatric hospitals: a qualitative study

ObjectiveThe aim of this study was to examine parents’ and healthcare professionals’ experiences and perceptions of parental readiness for resuscitation of their child in a paediatric hospital.DesignThis exploratory descriptive qualitative...

Use of Outpatient Opioids Prescribed From a Pediatric Acute Care Setting.

Deaths due to prescription opioid overdoses are at record high levels. Limiting the amount of opioid prescribed has been suggested as a prevention strategy, but little is known about how much is needed to adequately treat acutely painful conditions for outpatients. The purpose of this study was to quantify the usage of opioids prescribed from the pediatric emergency departments of a Midwestern tertiary care children's hospital system. This was a prospective descriptive study in which patients aged 0 to 17 years seen in 2 pediatric emergency departments who received a prescription for an outpatient opioid were enrolled. The main outcome was opioid doses used at home, which was obtained via phone follow-up. Additional information, including patient demographics, location, prescriber specialty, diagnosis, and opioid name and amount prescribed, was obtained via chart review. A total of 295 patients were enrolled, with 281 completing the study (95%). The median numbers of opioid doses prescribed and used were 12 and 2 doses, respectively, with 9 doses in excess. Patients with lower extremity fractures used more opioids than other diagnoses, with a median of 8 doses. The majority of families reported keeping extra doses at home. Prescribed opioid doses exceeded used doses by a factor of 6. Lower extremity fractures required more doses than other acutely painful conditions. We should consider limiting doses prescribed to decrease excess opioids available for misuse and abuse.

Evaluating use of changing technologies for rapid next-generation sequencing in pediatrics.

Rapid next-generation sequencing (NGS) offers the potential to shorten the diagnostic process and improve the care of acutely ill children. The goal of this study was to report our findings, including benefits and limitations, of a targeted NGS panel and rapid genome sequencing (rGS) in neonatal and pediatric acute clinical care settings. Retrospective analysis of patient characteristics, diagnostic yields, turnaround time, and changes in management for infants and children receiving either RapSeq, a targeted NGS panel for 4500+ genes, or rGS, at the University of Utah Hospital and Primary Children's Hospital, from 2015 to 2020. Over a 5-year period, 142 probands underwent rapid NGS: 66 received RapSeq and 76 rGS. Overall diagnostic yield was 39%. In the majority of diagnostic cases, there were one or more changes in clinical care management. Of note, 7% of diagnoses identified by rGS would not have been identified by RapSeq. Our results indicate that rapid NGS impacts acute pediatric care in real-life clinical settings. Although affected by patient selection criteria, diagnostic yields were similar to those from clinical trial settings. Future studies are needed to determine relative advantages, including cost, turnaround time, and benefits for patients, of each approach in specific clinical circumstances. The use of comprehensive Mendelian gene panels and genome sequencing in the clinical setting allows for early diagnosis of patients in neonatal, pediatric, and cardiac intensive care units and impactful change in management. Diagnoses led to significant changes in management for several patients in lower acuity inpatient units supporting further exploration of the utility of rapid sequencing in these settings. This study reviews the limitations of comparing sequencing platforms in the clinical setting and the variables that should be considered in evaluating diagnostic rates across studies.