Pediatric Acute Care Setting Research Articles

Opioid Prescribing Practices in Pediatric Acute Care Settings.

Deaths due to prescription opioid overdoses are at record-high levels. Limiting the amount of opioid prescribed has been suggested as a prevention strategy. The purpose of this study was to describe the opioid prescribing practices in the emergency departments and urgent care sites of a Midwestern tertiary care children's hospital system. This retrospective medical record review examined the visits from the 2 pediatric emergency departments and 2 pediatric urgent care sites in the system from June 1, 2012, to May 31, 2013, during which an outpatient opioid prescription was written. The primary outcome was number of days of opioid prescribed. Other data collected included patient demographics, diagnosis, and prescriber information; factors associated with prescriptions written for more than 5 days were identified. A total of 4075 opioid prescriptions were included in the 1-year study period, and 3991 of these had complete data for analysis. The median amount prescribed was 3.3 days with an interquartile range of 2.5 days. Odds of receiving a prescription of more than 5 days' duration were higher for children younger than 1 year (odds ratio [OR], 12.3; 95% confidence interval [CI], 7.3-21.0), 1 to 4 years of age (OR, 7.7; 95% CI, 5.5-10.8), and 5 to 9 years of age (OR, 2.4; 95% CI, 1.7-3.4); for children with noninjury diagnoses (OR, 1.4; 95% CI, 1.2-1.7); or if prescribed by a resident physician (OR, 1.4; 95% CI, 1.1-1.8) or from the urgent care (OR, 1.4; 95% CI, 1.1-1.7). Opioid prescriptions of more than 5 days were more frequently prescribed for younger patients, noninjury diagnoses, or if prescribed by a resident physician or from the urgent care. We need to focus on medical student, resident, and provider education as well as further opioid research in order to decrease unnecessary prescribing.

The Association of the Nurse Work Environment and Patient Safety in Pediatric Acute Care.

Eighteen years ago, the Institute of Medicine estimated that medical errors in hospital were a major cause of mortality. Since that time, reducing patient harm and improving the culture of patient safety have been national health care priorities. The study objectives were to describe the current state of patient safety in pediatric acute care settings and to assess whether modifiable features of organizations are associated with better safety culture. An observational cross-sectional study used 2015-2016 survey data on 177 hospitals in four U.S. states, including pediatric care in general hospitals and freestanding children's hospitals. Pediatric registered nurses providing direct patient care assessed hospital safety and the clinical work environment. Safety was measured by items from the Agency for Healthcare Research and Quality's Culture of Patient Safety survey. Hospital clinical work environment was measured by the National Quality Forum-endorsed Practice Environment Scale. A total of 1875 pediatric nurses provided an assessment of safety in their hospitals. Sixty percent of pediatric nurses gave their hospitals less than an excellent grade on patient safety; significant variation across hospitals was observed. In the average hospital, 46% of nurses report that mistakes are held against them and 28% do not feel safe questioning authority regarding unsafe practices. Hospitals with better clinical work environments received better patient safety grades. The culture of patient safety varies across U.S. hospital pediatric settings. In better clinical work environments, nurses report more positive safety culture and higher safety grades.

Impact of Synchronous Telemedicine Models on Clinical Outcomes in Pediatric Acute Care Settings: A Systematic Review.

To evaluate the impact of synchronous telemedicine models on the clinical outcomes in pediatric acute care settings. Citations from EBM Reviews, MEDLINE, EMBASE, Global Health, PubMed, and CINAHL. We identified studies that evaluated the impact of synchronous telemedicine on clinical outcomes between January 2000 and April 2018. All studies involving acutely ill children in PICUs, pediatric cardiac ICUs, neonatal ICUs, and pediatric emergency departments were included. Publication inclusion criteria were study design, participants characteristics, technology type, interventions, settings, outcome measures, and languages. Two authors independently screened each article for inclusion and extracted information, including telecommunication method, intervention characteristics, sample characteristics and size, outcomes, and settings. Out of the 789 studies initially identified, 24 were included. The six main outcomes of interest published were quality of care, hospital and standardized mortality rate, transfer rate, complications and illness severity, change in medical management, and length of stay. The use of synchronous telemedicine results improved quality of care and resulted in a decrease in the transfer rate (31-87.5%) (four studies), a shorter length of stay (8.2 vs 15.1 d) (six studies), a change or reinforcement of the medical care plan, a reduction in complications and illness severity, and a low hospital and standardized mortality rate. Overall, the quality of the included studies was weak. Despite the broad recommendations found for using telemedicine in pediatric acute care settings, high-quality evidence of its impacts is still lacking. Further robust studies are needed to better determine the clinical effectiveness and the associated impacts of telemedicine in pediatric acute care settings.

A comprehensive systematic review of stakeholder attitudes to alternatives to prospective informed consent in paediatric acute care research

BackgroundA challenge of performing research in the paediatric emergency and acute care setting is obtaining valid prospective informed consent from parents. The ethical issues are complex, and it is important to consider the perspective of participants, health care workers and researchers on research without prospective informed consent while planning this type of research.MethodsWe performed a systematic review according to PRISMA guidelines, of empirical evidence relating to the process, experiences and acceptability of alternatives to prospective informed consent, in the paediatric emergency or acute care setting. Major medical databases and grey sources were searched and results were screened and assessed against eligibility criteria by 2 authors, and full text articles of relevant studies obtained. Data were extracted onto data collection forms and imported into data management software for analysis.ResultsThirteen studies were included in the review consisting of nine full text articles and four abstracts. Given the heterogeneity of the methods, results could not be quantitatively combined for meta-analysis, and qualitative results are presented in narrative form, according to themes identified from the data. Major themes include capacity of parents to provide informed consent, feasibility of informed consent, support for alternatives to informed consent, process issues, modified consent process, child death, and community consultation.ConclusionOur review demonstrated that children, their families, and health care staff recognise the requirement for research without prior consent, and are generally supportive of enrolling children in such research with the provisions of limiting risk, and informing parents as soon as possible. Australian data and perspectives of children are lacking and represent important knowledge gaps.

28.0 Management of Agitation/Aggression in the Pediatric Emergency Department, Inpatient Pediatrics Floor, and Beyond

Agitation in pediatric acute care settings is common and disruptive. We begin with a case example of an agitated patient on a pediatric medical unit. Data from a survey of 38 North American children’s hospitals will outline the prevalence, screening methods, clinical guidelines, and physician training in the management of agitation. We will describe two children’s hospitals’ practices and summarize the literature on medications for agitation. We conclude with the Consensus Guidelines for PRN Medication for Agitation in the emergency department.

Precision, Sensitivity and Patient Preference of Non-Invasive Thermometers in a Pediatric Surgical Acute Care Setting

PurposeThe purpose of the project was to compare the temporal artery thermometer (TAT) to the digital probe thermometer readings at axillary or oral sites, to determine the relative precision and sensitivity of the three methods of thermometry, to compare their readings to core temperature when feasible, and to survey patient and family thermometer preferences. Design & MethodsA randomized crossover design in a 70-bed surgical unit over eight months. Two sets of temperature measurements were obtained for each patient: TAT, axillary, oral (depending on patient ability) and a bladder temperature representing core body temperature (when available). Each method was used twice on each patient, to examine within-method precision. Following measurement, patients or caregivers provided their thermometer preference. For younger/nonverbal patients, a professional observer recorded a disruption score. N=298 patients were enrolled ResultsTAT was more precise than oral and axillary thermometers (p<0.001 vs. axillary, p=0.001 vs. oral). TAT measurements were higher on average than axillary and oral, by 0.7°C and 0.6°C respectively (p<0.001). TAT's disruption score for younger patients was 0.6 points lower on average than axillary (p<0.001). 84% of patients and families who indicated a clear thermometry preference chose TAT. Only 3 patients had bladder-temperature devices, and therefore accuracy could not be analyzed. ConclusionsTAT is more precise, more fever sensitive, less disruptive to younger children, and more preferred by patients and families. Practice ImplicationsTAT is an acceptable temperature measure that could be substituted for oral or axillary temperature in acute care pediatric settings.

Pain-Less Practice: Techniques to Reduce Procedural Pain and Anxiety in Pediatric Acute Care

Strategies for controlling procedural pain and anxiety are critical in the pediatric patient. Evolving tools and techniques allow the pediatric acute care provider to have an array of pharmacologic and nonpharmacologic options to aid in procedural care. Optimizing noninvasive pain and anxiety management can help providers in urgent care and ambulatory settings to perform procedures that may otherwise require care in an emergency department or anesthesia suite. This article introduces the concept of a “PainLESS Practice”—an evidence-based, tiered approach to procedural pain and anxiety management in acute care. The goal of a PainLESS Practice is not necessarily to eliminate patients' pain, but rather, to reduce pain and anxiety to a level that is tolerable and facilitate the performance of procedures. We will discuss methods of procedural pain control in the pediatric acute care setting starting from less invasive and progressing to more invasive, keeping in mind that multiple modalities may be used simultaneously or in sequence. These techniques vary depending on the patient's age, procedure being performed, and the patient's individual circumstances.

Puppets in an acute paediatric unit: Nurse’s experiences

Puppets have been used for play and in education with children in a variety of contexts, including health care. There is however a dearth of literature that explains nurses’ experiences when using puppets in a paediatric health care context nor any process to guide how they use puppets. In 2007 an educational framework called the Pup-Ed (KRS Simulation) was developed to assist nurses and educators in using puppets. In 2012 nurses (n=13) from a regional paediatric acute care setting, who had been educated in the Pup-Ed (KRS Simulation) framework, described their experiences using puppets when caring for sick children. Participants reported that the principles of the Pup-Ed (KRS Simulation) framework including the users’ knowledge/hidden nurse, a consistent history and silent voice all contributed to the central theme called connecting to optimise care. The puppets were a means to educate the children and were a source of distraction from unpleasant procedures. Additionally the puppets were a strategy to reduce fear and break down barriers for the child especially when undergoing procedures. When using the puppets participants identified that infection transfer was something to be considered and not all nurses felt comfortable using the puppets. A lack of confidence and time were identified as barriers to using the puppets. The findings from this study have been valuable in establishing recommendations for future puppet use.

Detection of airborne respiratory syncytial virus in a pediatric acute care clinic.

Respiratory syncytial virus (RSV) is the most common cause of respiratory illness in infants and young children, but this virus is also capable of re-infecting adults throughout life. Universal precautions to prevent its transmission consist of gown and glove use, but masks and goggles are not routinely required because it is believed that RSV is unlikely to be transmitted by the airborne route. Our hypothesis was that RSV is present in respirable-size particles aerosolized by patients seen in a pediatric acute care setting. RSV-laden particles were captured using stationary 2-stage bioaerosol cyclone samplers. Aerosol particles were separated into three size fractions (<1, 1-4.1, and ≥4.1 μm) and were tested for the presence of RSV RNA by real-time PCR. Samplers were set 152 cm ("upper") and 102 cm ("lower") above the floor in each of two examination rooms. Of the total, 554 samples collected over 48 days, only 13 (or 2.3%) were positive for RSV. More than 90% of the RSV-laden aerosol particles were in the ≥4.1 μm size range, which typically settle to the ground within minutes, whereas only one sample (or 8%) was positive for particles in the 1-4.1 μm respirable size range. Our data indicate that airborne RSV-laden particles can be detected in pediatric outpatient clinics during the epidemic peak. However, RSV airborne transmission is highly inefficient. Thus, the logistical and financial implications of mandating the use of masks and goggles to prevent RSV spread seem unwarranted in this setting. Pediatr Pulmonol. 2017;52:684-688. © 2016 Wiley Periodicals, Inc.

Diagnosis of Lyme disease in the pediatric acute care setting.

We review the current evidence concerning the diagnosis of Lyme disease in children for application in the acute care setting. Recent studies suggest that Lyme disease incidence is substantially higher than previously described. Although efforts are ongoing to identify alternative testing strategies, two-tiered serologic testing remains the diagnostic standard in children with compatible clinical syndromes. Published clinical prediction rules can assist clinicians caring for children with potential Lyme disease. Two-tiered serologic testing remains the mainstay of the diagnosis of Lyme disease. To minimize the risk of a false positive test, serologic testing should be limited to those children with symptoms compatible with Lyme disease with potential exposure to ticks from endemic regions.

A Randomized Controlled Trial of Defervescent Efficacy of Oral versus Rectal Paracetamol in a Pediatric Acute Care Setting

Objective : To assess the comparative efficacy of oral versus rectal paracetamol in reducing fever in a pediatric acute care setting. Methods : 200 children with body temperature >39oc were randomized to receive oral or rectal paracetamol, together with tepid sponging. Their body temperatures were measured at enrollment, after fever reduction protocol had been completed and at 30-minute and 60-minute intervals. General linear model was used to assess the effect of time and type of medication on fever reduction. Results : Mean log [temperature] differed significantly between time intervals (F(1.275, 248.576) = 32.766, p<0.001) and the test of between subject effects showed that there was a significant effect of antipyretic types on mean body temperature of children at different time intervals (F(1, 995) = 4.040, p<0.05). Conclusion : Rectal paracetamol was shown to be more effective overall at lowering body temperature, especially at the termination of fever reduction protocol, and at 60 minutes. Keywords : Paracetamol, fever, rectal suppository, defervescence

Pain management in the acute care setting: Update and debates.

Pain management in the paediatric acute care setting is underutilised and can be improved. An awareness of the analgesic options available and their limitations is an important starting point. This article describes the evolving understanding of relevant pharmacogenomics and safety data of the various analgesic agents with a focus on agents available in Australia and New Zealand. It highlights the concerns with the use of codeine in children and discusses alternative oral opioids. Key features of oral, parenteral, inhaled and intranasal analgesic agents are discussed, as well as evidence supported use of sweet tasting solutions and non-pharmacological interventions. One of the biggest changes in acute care pain management has been the advent of intranasal fentanyl providing reliable potent analgesia without the need for intravenous access. The article will also address the issue of multimodal analgesia where a single agent is insufficient.

Quality in paediatric emergency medicine: Measurement and reporting.

There is a clear demand for quality in the delivery of health care around the world; paediatric emergency medicine is no exception to this movement. It has been identified that gaps exist in the quality of acute care provided to children. Regulatory bodies in Australia and New Zealand are moving to mandate the implementation of quality targets and measures. Within the paediatric emergency department (ED), there is a lack of research into paediatric specific indicators. The existing literature regarding paediatric acute care quality measures has been recently summarised, and expert consensus has now been reported. It is clear that there is much work to be performed to generalise this work to ED. We review suggestions from the current literature relating to feasible indicators within the paediatric acute care setting. We propose options to develop a quality 'scorecard' that could be used to assist Australian and New Zealand EDs with quality measurement and benchmarking for their paediatric patients.

Family Adversity and Resilience Measures in Pediatric Acute Care Settings.

Adverse childhood experiences (ACEs) impact health across the life course. The purpose of this study was to identify caregiver ACEs, current adversity, and resilience in families seeking care in pediatric acute care settings. Study aims included identifying demographic characteristics, current adversities, and resilience measures associated with caregiver ACEs ≥4. A cross-sectional survey study design was used and a convenience sample (n=470) recruited at emergency and urgent care settings of a large Midwest pediatric hospital system. Measures were self-reported. The original 10-item ACEs questionnaire measured caregiver past adversity. Current adversity was measured using the 10-item IHELP. The six-item Brief Resiliency Scale measured resilience, and WHO-5 Well-Being Index was used to measure depressive affect. Compared to participants with ACEs score of 0-3 participants with ACEs ≥4 were more likely to have multiple current adversities, increased risk of depression, and lower resilience. Caregivers using pediatric acute care settings carry a high burden of ACEs and current adversities. Caregiver ACEs are associated with current child experiences of adversity. Caregivers socioeconomic status and education level may not be an accurate indicator of a family's risks or needs. Pediatric acute care settings offer opportunities to access, intervene, and prevent childhood adversity.

Nurses in Action: A Response to Cultural Care Challenges in a Pediatric Acute Care Setting

Culturally congruent care is satisfying, meaningful, fits with people's daily lives, and promotes their health and wellbeing. A group of staff nurses identified specific clinical challenges they faced in providing such care for Hispanic and underserved Caucasian children and families in the pediatric medical-surgical unit of an urban regional children's hospital in the southeastern U.S. To address these challenges, an academic-practice partnership was formed between a group of nurse managers and staff nurses at the children's hospital and nursing faculty and graduate students at a local, research-intensive public university. Using the culture care theory, the partners collaborated on a research study to discover knowledge that would help the nursing staff resolve the identified clinical challenges. Twelve families and 12 healthcare providers participated. Data analysis revealed five care factors that participants identified as most valuable: family, faith, communication, care integration, and meeting basic needs. These themes were used to formulate nursing actions that, when applied in daily practice, could facilitate the provision of culturally congruent care for these children and their families. The knowledge generated by this study also has implications for healthcare organizations, nursing educators, and academic-practice partnerships that seek to ensure the delivery of equitable care for all patients.

Evaluation of Off-label Prescribing at a Children's Rehabilitation Center.

This study was developed to evaluate the incidence of off-label prescribing at a pediatric rehabilitation center. Secondary objectives were to describe the medications, patient age groups, and diagnoses most often associated with off-label prescribing. This was a prospective observational study conducted at an academic, inpatient children's rehabilitation center from November 11, 2011, to April 1, 2012. Patients younger than 16 years of age who received at least 1 prescription medication were included. Data were collected from the patients' electronic medical records. A total of 240 medications orders were placed during the study, with 57% written off-label. Thirty-five patients (88%) received at least 1 off-label medication. Forty-nine percent of the orders were for patients younger than the approved range, with 48% written for an unapproved indication, 2% for an alternative route of administration, and 1% for an unapproved age and indication. Children 2 to 12 years of age received 40% of the off-label orders, followed by adolescents with 37%. The therapeutic classes most often prescribed off-label were central nervous system agents and anti-infectives. Off-label prescribing was found in the majority of children receiving rehabilitative services, a rate as high or higher than that reported in pediatric acute care or clinic settings. The medications prescribed off-label most often were central nervous system agents, reflecting the need to study medications in the chronic rehabilitation population to optimize function in children with brain or spinal cord injury.

The NOVEL Project Update

The NOVEL Project Update

Pediatric obesity and safety in inpatient settings: a systematic literature review.

Pediatric obesity affects more than 16% of American children and is associated with worse outcomes in hospitalized patients. A systematic literature review was performed to identify studies of adverse care events affecting obese pediatric patients in the emergency room, operating room, or inpatient wards. We systematically searched Medline for articles published from 1970 to 2013 regarding obesity and patient safety events in pediatric acute care settings. We determined the study design, number of patients studied, definition and prevalence of obesity, the relevant acute care setting, the specific association with obesity addressed, and the results of each study. Thirty-four studies documented both procedural complications and issues with general hospital care. Most were retrospective and focused on surgery or anesthesia. Obese patients may have increased risk for a variety of adverse events. Further study could improve institutional patient safety guidelines to enhance care for obese children.

Evaluating the feasibility of a parent‐briefing intervention in a pediatric acute care setting

The purpose of this study was to test the feasibility of a parent-briefing intervention for parents of hospitalized children with complex healthcare needs. A phase I, single-group, posttest study. There were 18 physicians, 25 nurses, and 31 parents who participated in the study. Participants were asked to sit while carrying out the briefings with parents. Parents and clinicians completed a feasibility questionnaire post briefings. Sixty-eight briefings were carried out. Parents and nurses evaluated the briefings in a favorable manner, whereas physicians' ratings were mixed. Further inquiry is recommended to understand the effects of a structured communication intervention on parent-professional decision-making practices.

The introduction of web-based video-consultation in a paediatric acute care setting

The Royal Children's Hospital (RCH) in Melbourne has been providing web-based video-consultations for a range of paediatric sub-specialties since 2011. There were 346 video-consultations in the first 16 months, from a total of 65 clinicians. Most teleconsultations were with the family at home. Generally, video-consultation was used for follow-up, after at least one face-to-face visit. A total of 132 users (specialist and regional clinicians, patients and families) responded to an online survey. The major reason for both clinicians and families participating in telehealth was the savings in families' travel time. Key factors for the successful implementation of telehealth at the RCH include: a clear organisational vision; simple web-based technology; clinician ownership; sustained support. The RCH experience suggests that telehealth is suitable for both simple and highly complex paediatric patients.