Pediatric 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.

Delays in diagnosis of nephrotic syndrome in children: A survey study.

Clinical experience suggests that childhood nephrotic syndrome is frequently diagnosed incorrectly, leading to delays in providing effective treatment. We hypothesized that the health care setting is an important determinant of diagnostic success, with implications for the patient and family health care experience. Our objectives were: (1) to characterize the relationship between diagnostic success and health care setting for the diagnosis of nephrotic syndrome, (2) to determine types and frequencies of incorrect diagnoses, and (3) to understand the burden placed on patients and families as a result of incorrect and incomplete diagnoses. A survey was conducted by phone or in-person with legal guardians of children 1 to 18 years diagnosed with nephrotic syndrome within 24 months before the study. The survey elicited information on type of health care setting utilized (e.g., family practice, emergency room) and on diagnoses and treatments. Seventy-four patients with varying ethnicities and socioeconomic profiles (37 male, 37 female, median age 4.8 years, range: 1.2 to 14.8) were included from four Canadian paediatric nephrology centres. Proportions of diagnostic success were high in emergency and paediatric care settings (66% and 64% correct, respectively), but low in primary care settings (17% family practice and 17% walk-in clinic, respectively). Diagnostic delays ranged from 0 to 428 days (median 9.5, interquartile range [IQR] = 20.5). "Allergies" was the most common incorrect diagnosis (47%). Parents and legal guardians reported missed work (55%) and added expenses (50%) prior to obtaining a correct diagnosis. Childhood nephrotic syndrome is often incorrectly diagnosed, especially in primary care settings.

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.

Effect of Nursing Intervention on Students’ Stressors related to their Training in Pediatric Critical Care Settings

The clinical experience is frequently perceived as a stressor in clinical education by nursing students. This study is a quasi-experimental aimed to assess the stressors related to students' training in pediatric critical care settings (PCCSs), study the factors affecting students' training in PCCSs, design, implement and evaluate nursing intervention based on needs assessment of the students. This study was conducted at Pediatric Nursing Departments inboth Faculty of Nursing/Ain Shams and El-Fayoum Universities. The study involved 120 purposive students in the 3rd academic year/ Pediatric Nursing Department regardless their age, residence and socioeconomic standards. Tools of the data collection were used pre and post nursing intervention namely, pre designed interviewing questionnaire (to assess the students' characteristics, data about factors that affect the students’ training in PCCSs as well, the stressors perceived by the students in their training and the students’ knowledge related to their training in PCCSs), Hamilton Rating Scale (to assess the students' anxiety level). The main results of the study showed that, there was a statistical significant difference between the students' knowledge regarding to PCCSs and total stress level pre and post nursing intervention among the study group compared with the control group. The study concluded that, the application of nursing intervention reduce the students’ stressors related to their training in pediatric critical care settings. The study recommended orientation program, identifying students’ needs in the pediatric critical care settings and developing effective nursing interventions to reduce their stress

Paediatric Pain Medicine: Pain Differences, Recognition and Coping Acute Procedural Pain in Paediatric Emergency Room.

Paediatric pain and its assessment and management are challenging for medical professionals, especially in an urgent care environment. Patients in a paediatric emergency room (PER) often undergo painful procedures which are an additional source of distress, anxiety, and pain. Paediatric procedural pain is often underestimated and neglected because of various myths, beliefs, and difficulties in its evaluation and treatment. However, it is very different from other origins of pain as it can be preventable. It is known that neonates and children can feel pain and that it has long-term effects that last through childhood into adulthood. There are a variety of pain assessment tools for children and they should be chosen according to the patient’s age, developmental stage, communication skills, and medical condition. Psychological factors such as PER environment, preprocedural preparation, and parental involvement should also be considered. There are proven methods to reduce a patient’s pain and anxiety during different procedures in PER. Distraction techniques such as music, videogames, virtual reality, or simple talk about movies, friends, or hobbies as well as cutaneous stimulation, vibration, cooling sprays, or devices are effective to alleviate procedural pain and anxiety. A choice of distraction technique should be individualized, selecting children who could benefit from nonpharmacological pain treatment methods or tools. Nonpharmacological pain management may reduce dosage of pain medication or exclude pharmacological pain management. Most nonpharmacological treatment methods are cheap, easily accessible, and safe to use on every child, so it should always be a first choice when planning a patient’s care. The aim of this review is to provide a summary of paediatric pain features, along with their physiology, assessment, management, and to highlight the importance and efficacy of nonpharmacological pain management in an urgent paediatric care setting.

The Role of Antifungals in Pediatric Critical Care Invasive Fungal Infections.

Invasive fungal infections (IFIs) have seen considerable increase in pediatric intensive care units over the past several decades. IFIs are predominantly caused by Candida species, and candidemia is the third most common cause of healthcare-associated bloodstream infections (BSIs) in children. IFIs are opportunistic infections that affect pediatric patients in critical care resulting in significant morbidity and mortality especially in those with a compromised immune system. IFIs are the leading cause of death in children with comorbidities such as immunosuppression, and pediatric ICU admission has been shown to be an independent risk factor for mortality. Management of IFI and fungal sepsis is broad and encompasses several key components that include prompt initiation of therapy and rapid source identification and control. This study reviews important antifungals in the pediatric critical care setting including the pharmacologic properties, antifungal spectrum, adverse effects, and clinical uses of agents belonging to the four major classes of antifungals—the polyenes, azoles, echinocandins, and pyrimidine analogue flucytosine. The polyenes and azoles are the most often used classes of antifungals. The echinocandins are a relatively newer class of antifungal agents that offer excellent Candida activity and are currently recommended as the first-line therapy for invasive candidiasis.

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.

Moral distress in paediatric oncology: Contributing factors and group differences.

Providing oncological care to children is demanding and ethical issues concerning what is best for the child can contribute to moral distress. To explore healthcare professionals' experiences of situations that generate moral distress in Swedish paediatric oncology. In this national study, data collection was conducted using the Swedish Moral Distress Scale-Revised. The data analysis included descriptive statistics and non-parametric analysis of differences between groups. Healthcare professionals at all paediatric oncology centres in Sweden were invited to participate. A total of 278 healthcare professionals participated. The response rate was 89%. In its advisory statement, the Regional Ethical Review Board decided that the study was of such a nature that the legislation concerning ethical reviews was not applicable. All participants received written information about the aim of the study and confidentiality. Participants demonstrated their consent by returning the survey. The two situations with the highest moral distress scores concerned lack of competence and continuity of personnel. All professional groups reported high levels of disturbance. Nurses rated significantly higher frequencies and higher total Moral Distress Scale scores compared to medical doctors and nursing assistants. Lack of competence and continuity, as the two most morally distressing situations, confirms the findings of studies from other countries, where inadequate staffing was reported as being among the top five morally distressing situations. The levels of total Moral Distress Scale scores were more similar to those reported in intensive care units than in other paediatric care settings. The two most morally distressing situations, lack of competence and continuity, are both organisational in nature. Thus, clinical ethics support services need to be combined with organisational improvements in order to reduce moral distress, thereby maintaining job satisfaction, preventing a high turnover of staff and ensuring the quality of care.

Perception of Patient Safety Culture in Pediatric Long-Term Care Settings.

Patient safety culture (PSC) is an emerging construct in adult long-term care settings. No measures are validated to quantify PSC in pediatric long-term care (pLTC) settings despite the importance of safety for this vulnerable population. The study purposes are to (1) describe PSC in pLTC, (2) assess the relationship of PSC to facility recommendation and overall safety rating, and (3) test the stability and reliability of the PSC survey over time. A modified Nursing Home PSC (NHSPSC) survey was administered to employees at three pLTC facilities over 3 years; data were summarized and compared over time. In all, 208 surveys were completed. Staff perceptions on "feedback and communication about incidents" and "overall perceptions of resident safety" were most positive and associated with responses of recommending the facility and high overall ratings for child safety (p < .05). The modified NHSPSC survey was reliable by Cronbach alpha and findings were consistent over time in these pLTC settings. This tool may be a useful adjunct to safety initiatives in pLTC. Knowledge derived from this survey can provide actionable information for consumers, pLTC employees, managers, and administrators.

The practice of transfusion and fluid bolus therapy in neonates

There is increasing uncertainty over the potential benefits and harms of volume expansion in paediatric and adult critical care settings. In addition, there are increasing numbers of reports of adverse effects and association with RBC transfusions in neonates, including transfusion‐associated necrotizing enterocolitis. Preterm infants &lt;28 weeks’ gestation in particular are likely more vulnerable to volume shifts and changes in blood pressure due to their unique physiology. This review paper will provide an overview of the current evidence base supporting the use of RBC transfusion thresholds and the use of fluid bolus therapy in neonates. We will argue that enhanced data collection and collaborations through neonatal networks, development of international consensus definitions of transfusion adverse effects and associations, as well as haemodynamic compromise in neonates, are needed to further advance research in these areas.

Risk Factors of Bloodstream Infections Caused by Carbapenem-Resistant Gram-Negative Pathogens in Pediatric Critical Care Settings

Risk Factors of Bloodstream Infections Caused by Carbapenem-Resistant Gram-Negative Pathogens in Pediatric Critical Care Settings

Sleep and Delirium in Pediatric Critical Illness: What Is the Relationship?

With growing recognition of pediatric delirium in pediatric critical illness there has also been increased investigation into improving recognition and determining potential risk factors. Disturbed sleep has been assumed to be one of the key risk factors leading to delirium and is commonplace in the pediatric critical care setting as the nature of intensive care requires frequent and invasive monitoring and interventions. However, this relationship between sleep and delirium in pediatric critical illness has not been definitively established and may, instead, reflect significant overlap in risk factors and consequences of underlying neurologic dysfunction. We aim to review the existing tools for evaluation of sleep and delirium in the pediatric critical care setting and review findings from recent investigations with application of these measures in the pediatric intensive care unit.

Anxiety-related disorders: An overview.

Anxiety-related disorders are common in the child and adolescent population. They cause significant distress, which can affect social, emotional, family and academic functioning. They frequently present in general paediatric and primary care settings. Comprehensive assessment should include the child as well as parent and family functioning because anxiety-related disorders in other family members are common and, if untreated, can affect outcomes for the child. There are good evidence-based psychological interventions available, which should be the first line of treatment offered; accessing appropriate therapies for an adequate duration of treatment can, however, be challenging. Medication, particularly selective serotonin reuptake inhibitors, may have a role to play but should be used in the context of psychologically based therapies. Prevention of anxiety-related disorders in childhood is a major public health issue. Prevention programmes are available and should commence in the antenatal period through infancy, early childhood and adolescence, promoting positive attachments and resilience.

Centering Care: The Role of Labyrinths for Fostering Reflection in Pediatric Palliative and Critical Care Settings

Centering Care: The Role of Labyrinths for Fostering Reflection in Pediatric Palliative and Critical Care Settings

Pediatric Malpractice Claims in the Emergency Department and Urgent Care Settings From 2001 to 2015.

This study aimed to provide an assessment of medical malpractice claims involving pediatric patients cared for in emergency department and urgent care settings. We performed a retrospective review of all closed malpractice claims involving children (0-17 years old) originating from emergency department or urgent care centers from the Physician Insurers Association of America's Data Sharing Project database for a 15-year period (2001-2015). Reported data collected include medical specialty involved, medical diagnoses, chief medical factors, severity of resulting injury, claim disposition, average indemnity, and average defense costs. A total of 728 closed claims in pediatric emergency care settings were reviewed. Money was paid to the claimant in 30% of cases (220/728), with a total of US $70.3 million (average $319,513) paid to patients or families during the 15-year period. The most common resulting medical conditions were cardiac or cardiorespiratory arrest, appendicitis, and disorder of male genital organs. Error in diagnosis was the most common chief medical factor (41%), whereas those that involved failure or delay in admission to the hospital, which was the eighth most common chief medical factor, resulted in the highest average indemnity. Of the 728 closed claims, 220 involved a patient death (30%), but claims involving major permanent injury more often resulted in a payment. Of the 57 cases that went to trial, verdicts favored the physician in 47 cases (82%). Cardiac conditions, appendicitis, and disorder of the male genital organs are the most common medical conditions, and error in diagnosis is the most common chief medical factor in pediatric emergency care malpractice suits. It is important for providers practicing in these settings to be familiar with the common diagnoses and chief medical factors involved in these claims.

Longitudinal Self-Management and/or Transition Readiness per the TRxANSITION Index among Patients with Chronic Conditions in Pediatric or Adult Care Settings

To evaluate the roles of key individual, family, and illness characteristics on the levels of and gains in longitudinal healthcare transition (HCT) readiness in the pediatric setting and/or self-management skills (SMS) in the adult-focused setting, we used a large dataset with longitudinal measurements from 2006 to 2015. This longitudinal observational study followed 566 adolescents and young adults with chronic conditions at University of North Carolina Hospitals. TRxANSITION Index measurements, which represent learning outcomes rather than health outcomes, were collected multiple times per patient and analyzed using a novel application of an education-based approach. Levels of and gains in HCT/SMS scores increased with age (P < .001) with smaller increases at older ages. Mastery of skills varied by age with self-management achieved after 20 years of age. Scores varied positively by father's education and negatively by mother's education and duration of diagnosis. Gains in scores further varied positively with private insurance and negatively with mother's education and duration of diagnosis. We found diminishing positive increases in HCT/SMS scores as patients become older and smaller levels of and gains in readiness among younger patients with more educated mothers. Risk factors for absolute level of HCT/SMS readiness and inadequate longitudinal gains are not always the same, which motivates a deeper understanding of this dynamic process through additional research. This information can guide providers to focus HCT/SMS preparation efforts on skills mastered at particular ages and to identify patients at risk for inadequate development of HCT/SMS skills.

Implementation of the Recommendations for RBC Transfusions for Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

To provide context for the implementation of the Pediatric Critical Care Transfusion and Anemia Expertise Initiative recommendations for RBC transfusions including a review of prior research related to implementation of transfusion guidelines, efforts to facilitate implementation through Transfusion and Anemia Expertise Initiative, and to provide a framework for recommendation implementation. Review of existing clinical literature and description of a comprehensive approach to implementation based on Implementation Science principles. The Transfusion and Anemia Expertise Initiative recommendations on RBC transfusions are based on clinical evidence and aim to limit unnecessary and potentially harmful transfusions. Prior efforts to use transfusion guidelines include use of provider education, local guidelines, visual aids, prospective and retrospective audit and feedback as well as computerized decision support tools; however, no single approach has been identified as optimal for implementation in pediatric critical care settings. Evidence around provider beliefs and transfusion decision-making point to the need for additional provider education, emphasizing the importance of limiting transfusions, and the development of recommendations, such as the Transfusion and Anemia Expertise Initiative guidelines, that can be applied to specific clinical conditions. The Transfusion and Anemia Expertise Initiative guidelines will be broadly disseminated; however, coordinated implementation efforts will be required to impact practice. An approach that encourages involvement of a wide range of multiprofessional stakeholders, formal agreement on the implemented guidelines, selection of strategies that are practical and feasible, and active monitoring of clinical practice and outcomes throughout implementation is recommended. A formal second stage Transfusion and Anemia Expertise Initiative - Continuous Assessment of Blood-use is proposed to enhance implementation of the recommendations, follow uptake and impact on practice and patient outcomes, and ensure integration of new clinical evidence into the existing guideline as it is developed.

An Ethical Claim for Providing Medical Recommendations in Pediatric Intensive Care.

The Declaration of Geneva was recently revised to emphasize patient autonomy and the importance of clinicians sharing medical knowledge. This reflects the welcome evolution of the doctor-patient relationship from one of paternalism to more informed, shared decision-making. Unfortunately, there is an increasing trend for clinicians to avoid making recommendations, instead providing a "menu" of care options from which patients and families must choose. This seems to be underpinned by the belief that it is unacceptably paternalistic to give guidance as to which course of action may be best to take. In this article, we argue that there is an ethical imperative for doctors to provide medical recommendations. This is discussed with particular emphasis on the pediatric critical care setting, where autonomy and shared decision-making are especially complex. We outline how a failure to provide clinical recommendations represents inadequate shared decision-making and erodes the doctor-patient relationship, leading to suboptimal care, paradoxically decreasing respect for autonomy. We describe an approach through which doctors can avoid paternalism without placing an undue burden of decision-making on families. We assert that patients' interests are best served by clinicians taking an active, relational role in shared decision-making, including exploration of values and giving explicit medical recommendations for care.

Practice Concepts and Innovations for Pediatric End-of-Life Care by the Interdisciplinary Care Team

In recent years, clinical approaches to anticipatory grief and inclusivity amongst the medical team and family members have grown. In thinking about the end-of-life concerns within the pediatric care setting, practice concepts, and innovations inform how physicians and members of the interdisciplinary care team choose to approach conversations with parents and family members, as well as the particular level of involvement parents should have in decisions regarding the end of their child’s life.