Pediatric Care Setting Research Articles

Being heard - Supporting person-centred communication in paediatric care using augmentative and alternative communication as universal design: A position paper.

Person-centred care, with its central focus on the patient in partnership with healthcare practitioners, is considered to be the contemporary gold standard of care. This type of care implies effective communication from and by both the patient and the healthcare practitioner. This is often problematic in the case of the paediatric population, because of the many communicative challenges that may arise due to the child's developmental level, illness and distress, linguistic competency and disabilities. The principle of universal design put forth in conventions and legislation means that the design of products and services should be usable by all people, to the greatest extent possible. Augmentative and alternative communication encompasses strategies, for example pictures and apps, that are typically used with people with communication disability. In this position paper, we argue for the universal use of augmentative and alternative communication to support person-centred communication and care for children, regardless of age or potential disability. Clinical examples are shared from three different paediatric care settings where pictorial supports were applied universally. Interviews were conducted with children and adolescents (with and without disabilities), parents and healthcare practitioners, and the principles of universal design were used as a framework to demonstrate how person-centred communication is supported in paediatric care.

Adverse Events And Emergency Department Opioid Prescriptions In Adolescents.

Understanding the risks associated with opioid prescription in adolescents is critical for informing opioid policy, but the risks are challenging to quantify given the lack of randomized trial data. Using a regression discontinuity design, we exploited a discontinuous increase in opioid prescribing in the emergency department (ED) when adolescents transition from "child" to "adult" at age eighteen to estimate the effect of an ED opioid prescription on subsequent opioid-related adverse events. We found that adolescent patients just over age eighteen were similar to those just under age eighteen, but they were 9.7percent more likely to be prescribed an opioid and 12.6percent more likely to have an adverse opioid-related event, defined as overdose, diagnosis of opioid use disorder, or long-term opioid use, within one year. We estimated a 14.1percent increased risk for an adverse outcome when "adults" just over age eighteen were prescribed opioids that would not have been prescribed if they were just under age eighteen and considered "children." Our results suggest that differences in care provided in pediatric versus adult care settings may be important to understanding prescribers' roles in the opioid epidemic.

Implementing a Watcher Program to Improve Timeliness of Recognition of Deterioration in Hospitalized Children

PurposeEarly recognition and response to clinical deterioration is critical to patient safety. Failures or delays in recognition and response often manifest as emergency transfers to the intensive care unit (ICU). We describe implementation of a program to improve recognition and response to clinical deterioration within the pediatric inpatient acute care setting (i.e., medical-surgical, hematology-oncology, and intermediate care units). Design and methodsWe assembled an inter-professional team including nurses, physicians, and hospital leaders to evaluate preventable patient harm events associated with failures in identifying and responding to clinical deterioration and resultant emergency transfers to the intensive care unit (ICU). We evaluated an existing situational awareness framework incorporating principles of high-reliability organizations, refined the framework utilizing internal event analyses data, and subsequently implemented a program reducing emergency transfers. ResultsEmergency transfers to the ICU from acute care settings decreased by more than 70%, and to date, this improvement has sustained. Nurses report increased satisfaction and empowerment to proactively escalate their concerns, respond to changes in a patient's condition, and reduce uncertainty about the plan of care. ConclusionsThe program has enhanced situational awareness, reduced emergency transfers, and fostered a culture of accountability and collaboration in alignment with the organizational core value of safety. Practice implicationsDeveloping a reliable system to support the healthcare team in recognizing and responding to clinical deterioration reduces the risk of care delays. Applying situational awareness to other high-risk situations, additional areas for program expansion were identified, to include emergency department admissions and behavioral health patients.

Assessment of the Implementation of Pharmacogenomic Testing in a Pediatric Tertiary Care Setting

Pharmacogenomic (PGx) testing provides preemptive pharmacotherapeutic guidance regarding the lack of therapeutic benefit or adverse drug reactions of PGx targeted drugs. Pharmacogenomic information is of particular value among children with complex medical conditions who receive multiple medications and are at higher risk of developing adverse drug reactions. To assess the implementation outcomes of a PGx testing program comprising both a point-of-care model that examined targeted drugs and a preemptive model informed by whole-genome sequencing that evaluated a broad range of drugs for potential therapy among children in a pediatric tertiary care setting. This cohort study was conducted at The Hospital for Sick Children in Toronto, Ontario, from January 2017 to September 2020. Pharmacogenomic analyses were performed among 172 children who were categorized into 2 groups: a point-of-care cohort and a preemptive cohort. The point-of-care cohort comprised 57 patients referred to the consultation clinic for planned therapy with PGx targeted drugs and/or for adverse drug reactions, including lack of therapeutic benefit, after the receipt of current or past medications. The preemptive cohort comprised 115 patients who received exploratory whole-genome sequencing-guided PGx testing for their heart conditions from the cardiac genome clinic at the Ted Rogers Centre for Heart Research. Patients received PGx analysis of whole-genome sequencing data and/or multiplex genotyping of 6 pharmacogenes (CYP2C19, CYP2C9, CYP2D6, CYP3A5, VKORC1, and TPMT) that have established PGx clinical guidelines. The number of patients for whom PGx test results warranted deviation from standard dosing regimens. A total of 172 children (mean [SD] age, 8.5 [5.6] years; 108 boys [62.8%]) were enrolled in the study. In the point-of-care cohort, a median of 2 target genes (range, 1-5 genes) were investigated per individual, with CYP2C19 being the most frequently examined; genotypes in 21 of 57 children (36.8%) were incompatible with standard treatment regimens. As expected from population allelic frequencies, among the 115 children in the whole-genome sequencing-guided preemptive cohort, 92 children (80.0%) were recommended to receive nonstandard treatment regimens for potential drug therapies based on their 6-gene pharmacogenetic profile. In this cohort study, among both the point-of-care and preemptive cohorts, the multiplex PGx testing program provided dosing recommendations that deviated from standard regimens at an overall rate that was similar to the population frequencies of relevant variants.

Implementing Rapid Whole-Genome Sequencing in Critical Care: A Qualitative Study of Facilitators and Barriers to New Technology Adoption

To characterize the views of members of the multi-disciplinary team regarding the implementation of rapid whole-genome sequencing (rWGS) as a first-tier test for critically ill children in diverse children's hospital settings. Qualitative interviews informed by implementation science theory were conducted with the multidisciplinary patient care teams and hospital leaders at each of the 5 tertiary care children's hospitals involved in a statewide rWGS implementation project. Our analysis revealed 5 key themes regarding the implementation process across the sites: the need for rWGS champions, educational needs and strategies, negotiating decision-making roles and processes, workflows and workarounds, and perceptions about rWGS. From the findings a composite clinical workflow diagram was developed to summarize all of the processes involved in the implementation of the test, and the key areas where implementation practices differed. These findings provide insights for design of interventions to support adoption, scale-up, and sustainability of rWGS and other novel technologies in neonatal and pediatric critical care settings.

Underdiagnosis of obesity in pediatric clinical care settings among children born preterm: a retrospective cohort study.

Neonatal care of preterm infants may include dietary approaches such as high calorie formulas to promote physical growth. However, continuing growth-promoting strategies beyond the point of necessity, coupled with poverty and food insecurity which are more common among families of children born preterm, may increase the risk of obesity. Because children born preterm tend to have more pressing health conditions that require ongoing care, obesity may go undiagnosed by providers. This retrospective cohort study included 38,849 children (31,548 term, 7301 preterm) born from 2010 to 2015, who received clinical care at a large pediatric medical center (Ohio, USA). Electronic medical record data, linked to Ohio birth certificates, were used to identify children with measured obesity (≥2 weight-for-length values ≥95th percentile before 24 months of age or BMI values ≥95th percentile at or after 24 months of age). Children were considered to have diagnosed obesity if their medical record had an obesity-related phrase or billing code recorded. Modified Poisson regression was used to compare risk of obesity undiagnosis among obese children born preterm versus at term. In total, 13,697 children had measured obesity, 10,273 (75%) of which were undiagnosed. Children born preterm with measured obesity were 8% more likely to be undiagnosed compared to children born at term (adjusted relative risk = 1.08 95% CI 1.05, 1.11). The risk was slightly higher for preterm children born to white women or born to women with higher educational attainment. For both groups, Primary Care and subspecialist clinics were the most common settings for undiagnosed obesity (74.9% and 16.8% of undiagnosed cases, respectively). Preterm birth was associated with increased risk of undiagnosed obesity in early childhood. This highlights the need to enhance obesity screening in the preterm population and to further explore reasons for this disparity.

Evaluation of a Sepsis Alert in the Pediatric Acute Care Setting.

Severe sepsis can cause significant morbidity and mortality in pediatric patients. Early recognition and treatment are vital to improving patient outcomes. The study aimed to evaluate the impact of a best practice alert in improving recognition of sepsis and timely treatment to improve mortality in the pediatric acute care setting. A multidisciplinary team adapted a sepsis alert from the emergency room setting to facilitate identification of sepsis in acute care pediatric inpatient areas. The sepsis alert included clinical decision support to aid in timely treatment, prompting the use of intravenous fluid boluses, and antibiotic administration. We compared sepsis-attributable mortality, time to fluid and antibiotic administration, proportion of patients who required transfer to a higher level of care, and antibiotic days for the year prior to the sepsis alert (2017) to the postimplementation phase (2019). We had 79 cases of severe sepsis in 2017 and 154 cases in 2019. Of these, we found an absolute reduction in both 3-day sepsis-attributable mortality (2.53 vs. 0%) and 30-day mortality (3.8 vs. 1.3%) when comparing the pre- and postintervention groups. Though our analysis was underpowered due to small sample size, we also identified reductions in median time to fluid and antibiotic administration, proportion of patients who were transferred to the intensive care unit, and no observable increase in antibiotic days. Electronic sepsis alerts may assist in improving recognition of sepsis and support timely antibiotic and fluid administration in pediatric acute care settings.

Application of the Spanish-Language Consultation and Relational Empathy (CARE) Measure to Assess Patient-Centered Care Among Latino Populations.

Reliable and valid measures are needed to assess the patient-centeredness of clinical care among Latino populations. We translated the Consultation and Relational Empathy (CARE) measure from English to Spanish and assessed its psychometric properties using data from 349 Latino parents/guardians visiting a pediatric clinic. Using confirmatory factor analysis, we examined the psychometric properties of the Spanish CARE measure. Internal reliability of the Spanish CARE measure was high (Omega coefficient = 0.95). Similar to the English-language CARE measure, factor analysis of the Spanish CARE measure yielded a single domain of patient-centeredness with high item loadings (factor loadings range from 0.79 to 0.96). This preliminary analysis supports the reliability and validity of the Spanish version of the CARE measure among Latinos in pediatric care settings. With further testing, the Spanish CARE measure may be a useful tool for tracking and improving the health care delivered to Latino populations.

Pediatric Fibrinogen PART I-Pitfalls in Fibrinogen Evaluation and Use of Fibrinogen Replacement Products in Children.

Fibrinogen is a key coagulation protein, playing a critical role in hemostasis. It is the first factor to decrease to critical levels during bleeding. Hypofibrinogenemia is an important risk factor for bleeding in clinical settings, including pediatric surgery. Yet, the optimal measurement of fibrinogen levels is subject to debate, as is the critical threshold for intervention. Fibrinogen replacement may be provided by cryoprecipitate and fibrinogen concentrate. Whilst both products contain fibrinogen, they are not equivalent, each has its own advantages and disadvantages, especially for pediatric use. Unfortunately, medical literature to support fibrinogen replacement in children is limited. In this article we review the current diagnostic tools to measure fibrinogen, with respect to their use in the pediatric critical care setting. Secondly, we evaluate the different fibrinogen replacement therapies, focusing on cryoprecipitate and fibrinogen concentrate and examine their individual product characteristics, associated risks and benefits, different dosing strategies and specific pitfalls for use in children. We summarize by highlighting current knowledge gaps and areas for future research.

Improving hospitalization in children and adolescents through animal assisted interventions (AAIS): A systematic review

IntroductionAnimal Assisted Interventions (AAIs) are increasingly introduced in pediatric care settings as a mean to promote the physical, mental, and emotional well-being of hospitalized children and adolescents and the humanization of the hospital environment.ObjectivesThe aim of this work was to review published studies implementing AAIs in hospital settings and to assess their effectiveness in reducing stress and pain, ameliorating social behavior, quality of life, and mood in pediatric patients. Reviewed interventions were also evaluated for their effects on caregiver’s stress and burden, as well as on perception of the work environment in hospital staff.MethodsStudies were systematically searched using PubMed, Scopus, ProQuest and Web of Science databases in accordance with PRISMA guidelines. The search was aimed at identifying studies examining the effects of AAIs on behavioral and physiological response to stress in children and adolescents (0-18 years) formally admitted to a hospital for a stay, as well as in those undergoing a visit for treatments or medical examinations.ResultsOf 350 studies screened, 17 were eligible for inclusion. Most of them focused on stress, pain and anxiety reduction in pediatric patients, and used both physiological parameters and behavioral observations/scales. The vast majority of the studies employed dogs. Results show the potential of AAIs to reduce anxiety and behavioral distress in pediatric patients, while acting on physiological measures associated with arousal.ConclusionsAlthough further studies of better quality are still needed, the findings of this review may have implications for clinical practices suggesting appropriate planning of AAIs by pediatric healthcare professionals.

Agreement Between Non-Invasive (Oscillatory) and Invasive Intra-Arterial Blood Pressure in the Pediatric Cardiac Critical Care Unit

We assessed the agreement between non-invasive (oscillatory) blood pressure (NIBP) measurements and invasive intra-arterial blood pressure (IBP) in the pediatric cardiac critical care unit. Children with intra-arterial lines as per standard management protocol were enrolled. NIBP was measured every 4 hourly and the corresponding IBP reading was recorded. A total of 839 brachial NIBP, 834 IBP femoral (IF), and 137 IBP radial (IR) readings were noted on 45 participants. The mean difference (95% CI) for agreement between NIBP and IF was -2.3 (-27.1, 22.5) mmHg for systolic, 0.9 (-21.3, 23.1) mmHg for diastolic and 0.3 (-23.3, 23.9) mmHg for mean BP. Similar results were found between NIBP and IR and between IF and IR. The interrater agreement [Kappa (95% CI)] was fair between NIBP and IF [0.54 (0.48, 0.61)], and IF and IR [0.62 (0.48, 0.76)] but lower between NIBP and IR [0.37(0.20, 0.55)] when values were classified as hypotensive, normotensive, and hypertensive. NIBP cannot replace but can supplement IBP in the pediatric cardiac critical care setting.

Development and feasibility testing of a play-based psychosocial intervention for reduced patient stress in a pediatric care setting: experiences from Pakistan

BackgroundHospitalization can be a source of great stress for children and their families. In high-income countries, there are specialized staff to help children cope using different techniques including play. However, it is a major challenge in low and middle-income countries (LMIC) due to financial constraints and untrained human resource. The objective of study was to develop and test the feasibility and acceptance of a psychology trainee-delivered model postulated on employing play as a means of enhancing child-parent interactions leading to reduced stress during hospitalization.MethodsThis study was conducted in the paediatric ward of a tertiary care private hospital in Pakistan. Pre-intervention survey revealed that parental stress stemmed mainly from seeing their child irritable, distressed, or in pain. Using a theory of change model, a play-based psychosocial intervention was developed to address these factors. The intervention approach was informed by principles of Nurturing Care Framework and play therapy. Children between birth and 6 years admitted in the acute care ward were eligible. The intervention was delivered between March 2019 and December 2020 by psychology trainees who were supervised by a clinical psychologist. The play-based sessions were delivered at the bedside and ranged from 20 to 40 min. Parents receiving the intervention were later interviewed for their stress, child emotions, and feedback about the service using structured surveys administered by psychology graduates. The trainees delivering the intervention were requested to provide their feedback as a written qualitative open-ended narrative. These narratives were analyzed using an inductive approach.ResultsThe survey was conducted with 223 families with about half of the sample having children under 2 years of age. Forty-five percent of parents reported play intervention to be one of 3 key factors in improving their experience during hospital stay. Only 5% of parents reported feeling stressed about the child illness after the intervention. Ninety to 96% parents felt respected, listened to, and understood by the therapists. Thematic analysis of the feedback by trainees indicated the internship to be a useful experience and a new avenue for professional life whereas physicians appreciated the interventions.ConclusionsThe authors conclude that psychology trainees can feasibly deliver a play-based intervention under supervision for reduced stress in children and their parents during hospitalization with mutual benefits.

A Clinical Communication Tool (Loop) for Team-Based Care in Pediatric and Adult Care Settings: Hybrid Mixed Methods Implementation Study.

BackgroundCommunication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and health care providers often experience poor communication and fragmented care. Through a sequential program of research, the Loop Research Collaborative developed a web-based, asynchronous clinical communication system for team-based care. Loop assembles the circle of care centered on a patient, in private networking spaces called Patient Loops. The patient, their caregiver, or both are part of the Patient Loop. The communication is threaded, it can be filtered and sorted in multiple ways, it is securely stored, and can be exported for upload to a medical record.ObjectiveThe objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research.MethodsThe study was a hybrid type II mixed methods design to simultaneously evaluate Loop’s clinical and implementation effectiveness, and implementation barriers and facilitators in 6 health care sites. Data included monthly user check-in interviews and bimonthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework for Implementation Research (CFIR), and Loop usage extracted directly from the Loop system.ResultsWe recruited 25 initiating health care providers across 6 sites who then identified patients or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 (range 0-28). The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital electronic medical records and patient portals were barriers to its adoption. While participants acknowledged Loop’s potential value for engaging the patient and caregiver, and for improving communication within the patient’s circle of care, Loop’s relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care.ConclusionsFundamental structural and implementation challenges persist toward realizing Loop’s potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for health care provider compensation for asynchronous communication.

Commentary: Evaluation of an evidence-based practice mentorship programme in a paediatric quaternary care setting.

Commentary: Evaluation of an evidence-based practice mentorship programme in a paediatric quaternary care setting.

Evaluation of an evidence-based practice mentorship programme in a paediatric quaternary care setting.

Evidence-based practice (EBP) is essential for clinical decision-making, improving care, reducing costs and achieving optimal patient outcomes. The Evidence-based Practice Mentorship Program (EBPMP) is a flexible, self-directed programme whereby participants carry out EBP projects guided by expert mentors. To evaluate EBPMP effectiveness and participant experience. To evaluate effectiveness, as measured by changes in EBP value, knowledge and implementation, participants completed pre- and post-EBPMP Quick-EBP-Value, Implementation and Knowledge (VIK) surveys. To understand participants' experiences individual and group interviews were conducted at the end of the programme and analysed using qualitative content analysis. Most participants were over 50 years old, Caucasian, inpatient staff nurses, baccalaureate prepared, with over 11 years' experience. Statistically significant improvements were observed in the post Quick-EBP-VIK knowledge and implementation domains. Individual and group participant interviews revealed four categories of importance to the experience: 1. perceived benefits of EBP, 2. time as a barrier to EBP, 3. desire for more cohort interaction and 4. positive mentee-mentor experience. EBPMP can improve participants' knowledge and implementation of EBP in an environment that values EBP; however, opportunities exist to implement programme modifications that address barriers identified by participants including project time and increased participant interactions.

Automated Analysis of Prescription Data to Reduce Prolonged Antibiotic Courses in the Pediatric Urgent Care Setting

Automated Analysis of Prescription Data to Reduce Prolonged Antibiotic Courses in the Pediatric Urgent Care Setting

Long-Term Daily Administration of Aprepitant for the Management of Intractable Nausea and Vomiting in Children With Life-Limiting Conditions: A Case Series

BackgroundNausea and vomiting is a common symptom in children through their end of life journey. Aprepitant, a NK-1 antagonist, has become a potent weapon in the fight against chemo-induced nausea and vomiting. However, its use in palliative care for refractory nausea and vomiting has been limited due to limited experience or evidence of continuous use. Emerging evidence suggests that continuous use is not only safe, but also effective in patients with nausea and vomiting refractory to multiple lines of antiemetic therapy. MethodsWe conducted a single centre retrospective chart review of children receiving care from a specialist palliative care team who were given continuous daily aprepitant for nausea and vomiting and were unresponsive to at least two prior lines of antiemetic therapy. Parental reports of the impact of nausea on mobility and feeding were used as proxy efficacy markers. Duration of effect and toxicity was also evaluated. ResultsTen children (eight with cancer as a primary diagnosis and two with noncancer diagnoses) received continuous aprepitant and all showed resolution of nausea and vomiting and an increased ability to mobilize and tolerate feeds. No adverse events noted. ConclusionOur review suggests a role for aprepitant in management of refractory nausea and vomiting, demonstrating safety and efficacy. This case series is the first report of aprepitant use in this manner in the paediatric palliative care setting.

Sepsis in the urgent care setting

Sepsis, in particular severe sepsis, is a major cause of morbidity and mortality in pediatrics. It is most likely to affect very young children and children with significant medical comorbidities. The definition of sepsis in pediatrics is currently rapidly evolving but the best treatment for children with severe sepsis remains early goal directed therapy with intravenous fluids and antibiotics. It is therefore important for any pediatric urgent care providers to be able to recognize and treat patients with severe sepsis. It is also important for pediatric urgent care providers to be aware of certain groups of patients who have an increased risk of mortality when they develop sepsis. This article summarizes the current understanding of pediatric sepsis and then focuses on the management of these patients in the pediatric urgent care setting, with special attention paid to groups at higher risks of negative outcomes.

Evaluation of a Systems-Wide Telebehavioral Health Training Implementation in Response to COVID-19.

In response to the Coronavirus disease 2019 pandemic, it became important to rapidly train mental health providers to provide telebehavioral health services (TBH) within a pediatric care setting. This study examined the perceived usefulness of various TBH training materials; provider motivation, comfort, and confidence in implementation of TBH services; and perceived benefits and barriers of TBH. After completing various training options and implementing TBH services for 1 month, providers indicated all training materials were helpful, with the recorded webinar being identified as the most helpful resource. This study describes the rapid training of mental health providers in preparation of system-wide TBH services.

User-Centered Design in Pediatric Acute Care Settings Antimicrobial Stewardship.

Antibiotic prescribing in ambulatory care centers is increasing. Previous research suggests that 20 to 50% of antibiotic prescriptions are either unnecessary or inappropriate. Unnecessary antibiotic consumption can harm patients by increasing antibiotic resistance and drug-associated toxicities, and the reasons for such use are multifactorial. Antimicrobial Stewardship Programs (ASP) were developed to guide better use of antibiotics. A core element of ASP is to provide feedback to clinical providers. To create clinically meaningful feedback, user-center design (UCD) is a robust approach to include end-users in the design process to improve systems. The study aimed to take a UCD approach to developing antibiotic prescribing feedback through input from clinicians in two ambulatory care settings. We conducted two group prototyping sessions with pediatric clinicians who practice in the emergency department and urgent care settings at a tertiary care children's hospital. Participants received background on the problem of antibiotic prescribing and then were interviewed about their information needs, perceived value, and desired incentives for a prescribing feedback system. Sessions concluded with their response and recommendations to sample sections of an antibiotic feedback report including orienting material, report detail, targeted education, and resources. A UCD approach was found to be highly valuable in the development of a feedback mechanism that is viewed as desirable by clinicians. Clinicians preferred interpreting the data themselves with aids such as diagrams and charts over the researcher concluded statements about the clinician's behavior. Specific feedback that clinicians considered redundant were removed from the model if preexisting alerts were established. Integrating a UCD approach in developing ASP feedback identified desirable report characteristics that substantially modified preliminary wireframes for feedback. Future research will evaluate the clinical effectiveness of our feedback reports in outpatient settings.