Pediatric Inpatient Care Research Articles

Quality and Safety of Pediatric Inpatient Care in Community Hospitals: A Scoping Review.

Although the majority of children are hospitalized in nonchildren's hospitals, little is known about the quality and safety of pediatric care in community hospitals. The aim of this study was to conduct a scoping review and synthesize literature on the quality and safety of pediatric inpatient care in United States community hospitals. We performed a systematic literature search in October 2016 to identify pediatric studies that reported on safety, effectiveness, efficiency, timeliness, patient-centeredness, or equity set in general, nonuniversity, or nonchildren's hospitals. We extracted data on study design, patient descriptors, and quality outcomes and assessed the risk of bias using modified Newcastle-Ottawa Scales. A total of 44 articles met the inclusion criteria. Study designs, patient populations, and quality outcome measures were heterogeneous; only three clinical domains, (1) perinatal regionalization, (2) telemedicine, and (3) imaging radiation, were explored in multiple studies with consistent directionality of results. A total of 30 studies were observational, and 22 studies compared community hospital quality outcomes with other hospital types. The remaining 14 studies reported testing of interventions; 12 showed improved quality of care postintervention. All studies reported an outcome addressing safety, effectiveness, or efficiency, whereas timeliness, patient-centeredness, and equity were infrequently addressed. Risk of bias was moderate or high for 72% of studies. Literature on the inpatient care of children in community hospitals is limited, making it difficult to evaluate healthcare quality. Measures of timeliness, patient-centeredness, and equity are underrepresented. The field would benefit from more multicenter collaborations to facilitate the application of robust study designs and to enable a systematic assessment of individual interventions and community hospital quality outcomes.

Anticipating pediatric patient transfers from intermediate to intensive care

Background Pediatric intermediate care units (IC) function to provide a higher level of inpatient pediatric care such as frequent monitoring or nursing intervention compared to routine inpatient general pediatric care. A small subset of these patients in IC deteriorate further and require transfer to the pediatric intensive care unit (PICU). By identifying patient characteristics at the time of admission that predict secondary transfer, specific monitoring, resource allocation and early intervention may be …

Analysis of Hierarchical Routine Data With Covariate Missingness: Effects of Audit & Feedback on Clinicians' Prescribed Pediatric Pneumonia Care in Kenyan Hospitals.

Background: Routine clinical data are widely used in many countries to monitor quality of care. A limitation of routine data is missing information which occurs due to lack of documentation of care processes by health care providers, poor record keeping, or limited health care technology at facility level. Our objective was to address missing covariates while properly accounting for hierarchical structure in routine pediatric pneumonia care.Methods: We analyzed routine data collected during a cluster randomized trial to investigating the effect of audit and feedback (A&F) over time on inpatient pneumonia care among children admitted in 12 Kenyan hospitals between March and November 2016. Six hospitals in the intervention arm received enhance A&F on classification and treatment of pneumonia cases in addition to a standard A&F report on general inpatient pediatric care. The remaining six in control arm received standard A&F alone. We derived and analyzed a composite outcome known as Pediatric Admission Quality of Care (PAQC) score. In our analysis, we adjusted for patients, clinician and hospital level factors. Missing data occurred in patient and clinician level variables. We did multiple imputation of missing covariates within the joint model imputation framework. We fitted proportion odds random effects model and generalized estimating equation (GEE) models to the data before and after multilevel multiple imputation.Results: Overall, 2,299 children aged 2 to 59 months were admitted with childhood pneumonia in 12 hospitals during the trial period. 2,127 (92%) of the children (level 1) were admitted by 378 clinicians across the 12 hospitals. Enhanced A&F led to improved inpatient pediatric pneumonia care over time compared to standard A&F. Female clinicians and hospitals with low admission workload were associated with higher uptake of the new pneumonia guidelines during the trial period. In both random effects and marginal model, parameter estimates were biased and inefficient under complete case analysis.Conclusions: Enhanced A&F improved the uptake of WHO recommended pediatric pneumonia guidelines over time compared to standard audit and feedback. When imputing missing data, it is important to account for the hierarchical structure to ensure compatibility with analysis models of interest to alleviate bias.

Pediatric diabetes inpatient care: can medical staff knowledge be improved?

Background The purpose of this study was to assess the benefit of a short workshop addressing knowledge and confidence of inpatient caregivers (physicians and nurses) treating pediatric type 1 diabetes mellitus (T1DM) patients. Methods Questionnaires to determine familiarity with T1DM management and confidence in care were distributed at three university-affiliated medical centers. A 5-h practical-skills workshop was conducted at one center. Same questionnaires were filled out immediately after the workshop and 3 months later. Evaluation of knowledge was based on 16 multiple-choice questions, and confidence based on 10 categorical questions. Results Nurses and physicians (total 135, 106 women, 85 nurses) completed the questionnaires. The median knowledge score was 53.33 (40-66) and 46.7 (26.7-66.7) for nurses and physicians, respectively (p = 0.76). The confidence scores were 1.44 (1.1-1.9) and 1.56 (1.2-1.8), respectively (p = 0.7). More experience among nurses (>10 years) was associated with higher confidence scores (p = 0.04). Twenty-one physicians and 52 nurses, 66 women, attended the workshop. The median knowledge grade improved from 60 (47-67) to 81 (69-81), p < 0.001, immediately after, and to 69 (63-81), p < 0.001, 3 months post-workshop. The median confidence score improved from 1.8 (1.6-2) to 2.4 (2.1-2.6), p < 0.001, and to 2.2 (2-2.6), p < 0.001, respectively. There was no association with profession or seniority. Conclusions Knowledge and confidence in care of medical staff treating inpatient T1DM pediatric patients are lacking. Both improved significantly after the workshop, independent of seniority or profession.

Achievable Benchmarks of Care for Pediatric Readmissions.

Most inpatient care for children occurs outside tertiary children's hospitals, yet these facilities often dictate quality metrics. Our objective was to calculate the mean readmission rates and the Achievable Benchmarks of Care (ABCs) for pediatric diagnoses by different hospital types: metropolitan teaching, metropolitan nonteaching, and nonmetropolitan hospitals. We used a cross-sectional retrospective study of 30-day, all-cause, same-hospital readmission of patients less than 18 years old using the 2014 Healthcare Utilization Project National Readmission Database. For each hospital type, we calculated the mean readmission rates and corresponding ABCs for the 17 most common readmission diagnoses. We define outlier as any hospital whose readmission rate fell outside the 95% CI for an ABC within their hospital type. We analyzed 690,949 discharges at 525 metropolitan teaching hospitals (550,039 discharges), 552 metropolitan nonteaching hospitals (97,207 discharges), and 587 nonmetropolitan hospitals (43,703 discharges). Variation in readmission rates existed among hospital types; however, sickle cell disease (SCD) had the highest readmission rate and ABC across all hospital types: metropolitan teaching hospitals 15.7% (ABC 7.0%), metropolitan nonteaching 14.7% (ABC 2.6%), and nonmetropolitan 12.8% (ABC not calculated). For diagnoses in which ABCs were available, outliers were prominent in bipolar disorders, major depressive disorders, and SCD. ABCs based on hospital type may serve as a better metric to explain case-mix variation among different hospital types in pediatric inpatient care. The mean rates and ABCs for SCD and mental health disorders were much higher and with more outlier hospitals, which indicate high-value targets for quality improvement.

Special Aspects in Pediatric Surgical Inpatient Care of Refugee Children: A Comparative Cohort Study.

Background: Recently, the number of refugees in Germany has skyrocketed, leading to a marked increase in refugee children admitted to hospitals. This study describes the special characteristics encountered in pediatric surgical inpatient refugees compared to locally residing patients. Methods: Hospital records of minor refugees admitted to our department from 2005 up to and including 2015 were retrospectively reviewed. Demographic data, diagnoses, comorbidities, body mass indexes, hemoglobin values, and lengths of stay were extracted and statistically compared to local patients. Results: A total of 63 refugee children were analyzed and compared to 24,983 locally residing children. There was no difference in median body mass index (16.2 vs. 16.3, respectively, p = 0.26). However, refugee children had significantly lower hemoglobin values (11.95 vs. 12.79 g/dL, p < 0.0001) and were more likely to be colonized with methicillin-resistant Staphylococcus. aureus (8% vs. 0.04%, p < 0.01). Refugees were much more likely to present with burn injuries (16% versus 3% of admissions, p < 0.001), esophageal foreign bodies (4% vs. 0.5%, p < 0.001), as well as trauma, except for closed head injury. Conclusion: The cohort of refugee children in this study was found to be at a particular risk for suffering from burn injuries, trauma, foreign body aspirations, and anemia. Appropriate preventive measures and screening programs should be implemented accordingly.

Identifying areas for improvement in paediatric inpatient care using the Child HCAHPS survey.

Within 6 weeks of discharge, 3,389 telephone surveys were completed by parents/guardians of children who were hospitalized for at least 24 hours. The survey was comprised of 66 questions, with responses based on Likert-scales. One survey question asked respondents to rate the overall care that their child received on a scale from 0 (worst care) to 10 (best care). The correlation between the overall rating of care and each survey measure and question was then examined using Spearman correlation coefficients. All survey questions were normalized to a 100-point score (0=worst, 100=best). Questions on provider coordination and nursing care were most correlated with overall experience. Quietness of hospital room (r=0.19, P<0.001), and keeping families informed in the emergency room (r=0.12, P<0.001) showed poor correlation. Correlation with overall experience was strongest for the 'communication with nurses' domain (r=0.46, P<0.001). To our knowledge, this is the first study which examines the correlation of individual questions of the Child-HCAHPS to overall rating of care within a Canadian context. Our results suggest that our large health care organization may attain initial inpatient experience improvements by focusing upon personnel-based initiatives, rather than physical attributes of our hospitals.

Adverse Events Associated with Risperidone Use in Pediatric Patients: A Retrospective Biobank Study.

BackgroundAlthough risperidone is increasingly used for behavioral indications in children, the associated adverse events (AEs) are not well defined in this population.ObjectiveWe determined the incidence of and risk factors for AEs among children treated with risperidone at our institution, an academic medical center with inpatient, outpatient, generalist, and specialist pediatric care.MethodsThe study included children aged ≤ 18 years with ≥ 4 weeks of risperidone exposure. Data were obtained using de-identified electronic health records. AEs were defined as any untoward event attributed to risperidone reported by the patient, parent/guardian, or physician or detected following a laboratory investigation. Associations between AEs and clinical variables were determined using univariate and multivariate analyses.ResultsThe study cohort included 371 individuals (median age 7.8 years [interquartile range 5.9–10.2]; 271 [73.0%] male). The two most common primary diagnoses were attention-deficit/hyperactivity disorder (160 [43.1%]) and autism (102 [27.5%]). The most frequent indications for risperidone were aggression (166 [44.7%]) and behavioral problems (114 [30.7%]). Altogether, 110 (29.6%) individuals had 156 AEs. Weight gain (32 [20.5%]) and extrapyramidal symptoms (23 [14.7%]) were the most common AEs. Aggression, irritability, and self-injurious behavior were positively associated with AEs, and concomitant analgesics and antibiotics were negatively associated. In multivariate analysis, associations remained significant for self-injurious behavior (adjusted odds ratio [aOR] 3.1; 95% confidence interval [CI] 1.7–5.4) and concomitant antibiotics (aOR 0.2; 95% CI 0.1–0.9).ConclusionsNearly one in three children treated with risperidone for ≥ 1 month experienced one or more AEs. Particular vigilance is warranted for children with self-injurious behavior.Electronic supplementary materialThe online version of this article (10.1007/s40801-019-0151-7) contains supplementary material, which is available to authorized users.

A mixed method multi-country assessment of barriers to implementing pediatric inpatient care guidelines.

IntroductionAccelerating progress in reducing child deaths is needed in order to achieve the Sustainable Development Goal child mortality target. This will require a focus on vulnerable children–including young children, those who are undernourished or with acute illnesses requiring hospitalization. Improving adherence to inpatient guidelines may be an important strategy to reduce child mortality, including among the most vulnerable. The aim of our assessment of nine sub-Saharan African and South Asian hospitals was to determine adherence to pediatric inpatient care recommendations, in addition to capacity for and barriers to implementation of guideline-adherent care prior to commencing the Childhood Acute Illness and Nutrition (CHAIN) Cohort study. The CHAIN Cohort study aims to identify modifiable risk factors for poor inpatient and post discharge outcomes above and beyond implementation of guidelines.MethodsHospital infrastructure, staffing, durable equipment, and consumable supplies such as medicines and laboratory reagents, were evaluated through observation and key informant interviews. Inpatient medical records of 2–23 month old children were assessed for adherence to national and international guidelines. The records of children with severe acute malnutrition (SAM) were oversampled to reflect the CHAIN study population. Seven core adherence indicators were examined: oximetry and oxygen therapy, fluids, anemia diagnosis and transfusion, antibiotics, malaria testing and antimalarials, nutritional assessment and management, and HIV testing.ResultsAll sites had facilities and equipment necessary to implement care consistent with World Health Organization and national guidelines. However, stockouts of essential medicines and laboratory reagents were reported to be common at some sites, even though they were mostly present during the assessment visits. Doctor and nurse to patient ratios varied widely. We reviewed the notes of 261 children with admission diagnoses of sepsis (17), malaria (47), pneumonia (70), diarrhea (106), and SAM (119); 115 had multiple diagnoses. Adherence to oxygen therapy, antimalarial, and malnutrition refeeding guidelines was >75%. Appropriate antimicrobials were prescribed for 75% of antibiotic-indicative conditions. However, 20/23 (87%) diarrhea and 20/27 (74%) malaria cases without a documented indication were prescribed antibiotics. Only 23/122 (19%) with hemoglobin levels meeting anemia criteria had recorded anemia diagnoses. HIV test results were infrequently documented even at hospitals with universal screening policies (66/173, 38%). Informants at all sites attributed inconsistent guideline implementation to inadequate staffing.ConclusionAssessed hospitals had the infrastructure and equipment to implement guideline-consistent care. While fluids, appropriate antimalarials and antibiotics, and malnutrition refeeding adherence was comparable to published estimates from low- and high-resource settings, there were inconsistencies in implementation of some other recommendations. Stockouts of essential therapeutics and laboratory reagents were a noted barrier, but facility staff perceived inadequate human resources as the primary constraint to consistent guideline implementation.

Young lives cut short: The relationship between firearms and pediatric suicide.

To describe the demographic characteristics and burden of pediatric suicides by firearm in the United States using a large all-payer pediatric inpatient care database. Children and young adults (<21 years old) were identified with an International Classification of Diseases, Ninth Revision diagnosis of suicide and self-inflicted injury with a firearm (SIF) in the Kids' Inpatient Database for the study years of 2006, 2009, and 2012. National estimates were obtained using case weighting. Multivariable logistic regression was performed to examine the association between SIF and risk factors while adjusting for various sociodemographic characteristics using separate models incorporating mental health diagnoses. There were a total of 613 hospitalizations for SIF during the years under study. Almost four hospitalizations per week occurred, and in-hospital mortality was 39.1%. The mean age of the study population was 17.3 years, and this population was predominantly male (87.5%), white (62.4%), resided in an urban area (43.8%), lived in the south (51.3%), and within the lowest income quartile (33.8%). Mental health (38.3%) and mood disorders (28.3%) were common. Males had a markedly increased likelihood of hospitalization for SIF (adjusted odds ratio [aOR], 7.56; 95% confidence interval [CI], 5.54-10.30). Children and adolescents from rural environments and those in the south were more likely to have a hospitalization for SIF than respective comparison groups. Using separate regression models, a diagnosis of any mental health disorder increased the likelihood of hospitalization for a SIF (aOR, 11.9: 95% CI, 9.51-14.9), mood disorders (aOR, 17.2; 95% CI, 13.3-22.3), and depression (aOR, 21.3; 95% CI, 16.1-28.3). Pediatric hospitalizations for SIF are a common occurrence with high associated mortality. The prevalence of mental health disorders and their impact on this population highlight the need for early identification and intervention for individuals at risk. Epidemiological, level III.

Addressing mental health stigma: A pilot educational video intervention for caregivers to facilitate psychiatric consultation in inpatient pediatric care settings.

Mental health stigma continues to be a significant barrier for psychiatric care in youth. Parental misperceptions regarding mental health may interfere with their child's care and negatively influence their child's view of mental health. For some children, their first experience with psychiatry occurs during medical hospitalization when they are seen by the Pediatric Consultation-Liaison (C/L) Psychiatry Service. Despite this unique role, there is sparse research on how to address mental health stigma with patients and families within the context of Pediatric C/L Psychiatry. This study explores the use of a brief educational video with messages from the Pediatric C/L Psychiatry team, families who have accessed mental health consultation in the hospital, and brief video interactions between family and the C/L team, to address mental health stigma. Common misconceptions are addressed during the video with the intent of reducing negative parental perceptions relating to mental health care. Families are given a survey highlighting these concerns, prior to and after watching the video. Pre- and post-intervention responses were compared using paired sample's t-tests. Results indicated that the video did positively change parent's confidence that psychiatry can be helpful, reduced their preconceived stigma regarding confidentiality, while alleviating concerns regarding psychotropic medication use in youth. Use of an educational video may be feasible, time efficient, and effective at reducing parental mental health stigma.

Weight Bias in Pediatric Inpatient Care

ObjectiveWeight bias can influence medical care but has not been studied in the pediatric inpatient setting. We will quantify implicit and explicit weight bias of pediatric inpatient providers and qualitatively explore providers’ attitudes toward children with obesity and patient/family perceptions of weight bias in the hospital. MethodsWe performed a mixed-methods study including semistructured key informant interviews and validated tests for implicit (Implicit Association Test) and explicit (Crandall's Anti-Fat Attitudes Questionnaire) bias with pediatric hospitalists, residents, and acute care nurses. We performed semistructured key informant interviews with pediatric inpatients aged 7 to 17 years and the patient's parent(s) or guardian(s). Interviews were coded using an inductive approach to identify recurrent themes. ResultsWe enrolled 28 pediatric providers, 12 patients, and 12 parents/guardians. In total, 71% of providers exhibited moderate or strong implicit weight bias, with generally lower scores for explicit bias. Qualitative analysis identified seven themes: the existence of weight bias, shared responsibility for a child's obesity, a potential for provider bias toward the parents of pediatric patients with obesity, possible effects of patient weight on inpatient care, importance of terminology in addressing obesity, and the possibility of addressing obesity inpatient but a preference for obesity to be addressed in the outpatient setting. ConclusionsHealth care providers, patients, and families in the pediatric inpatient setting identified multiple ways that obesity could impact care, including provider weight bias.

Barriers and enablers to implementing a virtual tertiary-regional Telemedicine Rounding and Consultation (TRAC) model of inpatient pediatric care using the Theoretical Domains Framework (TDF) approach: a study protocol

BackgroundOver-occupancy at the two tertiary pediatric care hospitals in Alberta, Canada is steadily increasing with simultaneous decline in occupancy of pediatric beds at regional hospitals. Over-occupancy negatively impacts timeliness and potentially, the safety of patient care provided at these two tertiary hospitals. In contrast, underutilization of pediatric beds at regional hospitals poses the risk of losing beds provincially, dilution of regional pediatric expertise and potential erosion of confidence by regional providers. One approach to the current situation in provincial pediatric care capacity is development of telemedicine based innovative models of care that increase the population of patients cared for in regional pediatric beds. A Telemedicine Rounding and Consultation (TRAC) model involves discussing patient care or aspects of their care using telemedicine by employing visual displays, audio and information sharing between tertiary and regional hospitals. To facilitate implementation of a TRAC model, it is essential to understand the perceived barriers among its potential users in local context. The current study utilizes qualitative methodologies to assess these perceived clinician barriers to inform a future pilot and evaluation of this innovative virtual pediatric tertiary-regional collaborative care model in Alberta.MethodsWe will use a qualitative descriptive design guided by the Theoretical Domain Framework (TDF) to systematically identify the tertiary and regional clinical stakeholder’s perceived barriers and enablers to the implementation of proposed TRAC model of inpatient pediatric care. Semi-structured interviews and focus groups with pediatricians, nurses and allied health professionals, administrators, and family members will be conducted to identify key barriers and enablers to implementation of the TRAC model using TDF. Appropriate behaviour change techniques will be identified to develop potential intervention strategies to overcome identified barriers. These intervention strategies will facilitate implementation of the TRAC model during the pilot phase.DiscussionThe proposed TRAC model has the potential to address the imbalance between utilization of regional and tertiary inpatient pediatric facilities in Alberta. Knowledge generated regarding barriers and enablers to the TRAC model and the process outlined in this study could be used by health services researchers to develop similar telemedicine-based interventions in Canada and other parts of the world.

Center Variation in Hospital Costs for Pediatric Heart Transplantation: The Relationship Between Cost and Outcomes.

There are limited published data addressing the costs associated with pediatric heart transplantation and no studies evaluating the variation in costs across centers. We aimed to describe center variation in pediatric heart transplant costs and assess the association of transplant hospitalization costs with patient outcomes. Using a linkage between the Pediatric Health Information System and Scientific Registry of Transplant Recipients databases, hospital costs were assessed for patients (< 18yearsof age) undergoing heart transplantation (2007-2016). Severity-adjusted patient costs were calculated using generalized linear mixed-effects models with a random hospital intercept. Center variation in hospital cost was described after adjusting for the predicted risk of in-hospital mortality. Post-transplant survival was compared between low- and high-cost centers using Cox proportional hazard models. A total of 2156 patients were included from 24 centers. There was 3.7-fold variation in transplant hospitalization costs across centers, ranging from $329,477 to $1,226,507. Patients transplanted at high-cost centers have a higher predicted risk of in-hospital mortality (8.1% vs. 6.1%, p < 0.001). Both early (p = 0.008) and long-term (p = 0.003) post-transplant survival were better in patients transplanted at low-cost centers. Transplant at low-cost centers was associated with improved post-transplant survival, independent of patient-specific risk (adjusted hazard ratio 0.72; 95%CI 0.57-0.92, p = 0.008). There is wide variation in cost for pediatric heart transplant inpatient care among U.S. centers with low-cost centers demonstrating the best patient survival. Differences in patient populations likely contribute to these findings, but cannot account for all the variation seen. This suggests that variability in the delivery of care across centers may influence post-transplant survival.

The Impact of Automated Electronic Surveillance of Electronic Medical Records on Pediatric Inpatient Care.

PurposeTo assess the impact of the automated surveillance of the electronic medical record process on clinical interventions among hospitalized children at a tertiary care pediatric center.MethodsA retrospective chart review of the alerts triggered for central line-associated blood stream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), neonatal sepsis, or clinical deterioration through elevated pediatric early warning scores (PEWS) by automated electronic surveillance of the hospital electronic medical record (EMR) over a five-month period among hospitalized children. Interventions instituted in response to the alerts were reviewed from the hospital EMR. Fisher’s exact test was performed to detect any significant difference in the proportion of interventions performed for alerts triggered between groups.ResultsA total of 244 alerts were collected (27 CAUTI, 55 CLABSI, 10 neonatal sepsis, and 152 PEWS alerts). A significant difference in the proportion of interventions instituted after neonatal sepsis and PEWS alerts (9/162, 5.6%) as compared to CLABSI and CAUTI alerts (20/82, 24.4%) was observed (p<0.001; Odds ratio (95% CI): 0.182 (0.079-0.422)). Neonatal sepsis triggered the least number of alerts (10/244, 4.1%) and proportionately fewer interventions than the other clinical alerts.ConclusionsAlerts for potential device-associated infections resulted in more clinical intervention than less-specific alerts. Neonatal sepsis alerts resulted in minimal interventions undertaken in response to the alert. Identifying and focusing on alerts benefitting the patient can serve as a better allocation of time and resources. Future studies should explore which newer alerts and their accompanying interventions improve patient outcomes.

Assessment of drug related problems and clinical pharmacist interventions in paediatric department of a tertiary care teaching hospital

Background: Drug-related problems (DRPs) are frequent in hospitalization in pediatrics. The main aim of present investigation is to assess drug related problems and clinical pharmacist interventions in pediatric department of tertiary care hospital.Methods: It was a prospective, observational and interventional study carried over a period of 6 months.Results: A total of 66 patients were identified with drug related problems. Among them 31 (42%) were in between 1month–2 years followed by 25 (34%) were in between 2-11 years, 10(24%) were in between 11-18 years of age. 30(45.3%) patients were prescribed with 0-3 drugs followed by 21 (31.3%) were prescribed with 3-5 drugs, 15(23.3%) were prescribed with 6-10 drugs. Most of the DRP’s observed in the study were drug interactions 52(78.78%) [major-19 (36.53%), moderate-27 (5192%) and minor-6(11.53%)] followed by adverse drug reactions 12 (18.18%), and duplication errors were 2 (3.03%). Majority of the clinical pharmacist recommendations were duration change 52 (34.66%), drug change 10(6.66%), dose reduction 2 (1.35%) followed by drug termination 2 (1.33%). Major significance of DRPs were noted high 31(57.96%), whereas 25 (39.8%) were moderate and 8 (12.12%) were minor. The acceptance rate of intervening clinical pharmacist recommendation and change in drug therapy was found to be high in 57 (86.66%) cases while in 9 (13.33%) cases suggestions were accepted but therapy was not changed. There were no cases with neither suggestion were accepted nor therapy changed.Conclusions: Clinical pharmacist involvement in inpatient pediatric care can significantly help to identify, resolve and prevent the drug related problems. The study concluded that the clinical pharmacist has a significant role in patients care at hospital.

Complexity of the pediatric trauma care process: Implications for multi-level awareness.

Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering (HFE) methods, we combine interview, archival document and trauma registry data to describe how intra-hospital care transitions affect process and team complexity. Specifically, we identify the 53 roles directly involved in patient care in each hospital unit and describe the 3324 total transitions between hospital units and the 69 unique pathways, from arrival to discharge, experienced by pediatric trauma patients. We continue the argument to shift from eliminating complexity to coping with it and propose supporting three levels of awareness to enhance the resilience and adaptation necessary for patient safety in health care, i.e. safety in complex systems. We discuss three levels of awareness (individual, team and organizational) and describe challenges and potential sociotechnical solutions for each. For example, one challenge to individual awareness is high time pressure. A potential solution is clinical decision support of information perception, integration and decision making. A challenge to team awareness is inadequate "non-technical" skills, e.g., leadership, communication, role clarity; simulation or another form of training could improve these. The complex, distributed nature of this process is a challenge to organizational awareness; a potential solution is to develop awareness of the process and the roles and interdependencies within it, by using process modeling or simulation.

Limitations of Using Pediatric Respiratory Illness Readmissions to Compare Hospital Performance.

Adult hospital readmission rates can reliably identify meaningful variation in hospital performance; however, pediatric condition-specific readmission rates are limited by low patient volumes. To determine if a National Quality Forum (NQF)-endorsed measure for pediatric lower respiratory illness (LRI) 30-day readmission rates can meaningfully identify high- and low-performing hospitals. Observational, retrospective cohort analysis. We applied the pediatric LRI measure and several variations to evaluate their ability to detect performance differences. Administrative claims from all hospital admissions in California (2012-2014). Children (age <18 years) with LRI (primary diagnosis: bronchiolitis, influenza, or pneumonia; or LRI as a secondary diagnosis with a primary diagnosis of respiratory failure, sepsis, bacteremia, or asthma). Thirty-day hospital readmission rates and costs. Hierarchical regression models adjusted for age, gender, and chronic conditions were used. Across all California hospitals admitting children (n = 239) using respiratory readmission rates, no outlier hospitals were identified with (1) the NQF-endorsed metric, (2) inclusion of primary asthma or secondary asthma exacerbation diagnoses, or (3) inclusion of 30-day emergency revisits. By including admissions for asthma, adding emergency revisits, and merging 3 years of data, we identified 9 outlier hospitals (2 high-performers, 7 low-performers). There was no association of hospital readmission rates with costs. Using a nationally-endorsed quality measure of inpatient pediatric care, we were unable to identify meaningful variation in hospital performance without broadening the metric definition and merging multiple years of data. Utilizers of pediatric-quality measures should consider modifying metrics to better evaluate the quality of pediatric care at low-volume hospitals. Supported by the Agency for Healthcare Research and Quality (K08 HS24592 to SVK and U18HS25297 to MDC and NSB) and the National Institute of Child Health and Human Development (K23HD065836 to NSB). The funding agency played no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the manuscript for publication.

Exploration of nurses' pediatric pain management experiences in rural hospitals: A qualitative descriptive study

BackgroundHospitalized children continue to experience inadequate pain management. Children in the rural hospital setting may be at risk due to unique challenges experienced by Registered Nurses (RNs) in this context. ObjectivesTo understand the experience of pain care from RNs who work in rural hospitals with inpatient pediatric patients. DesignQualitative description that used semi-structured interviews to explore RNs' inpatient pediatric pain care experiences. ParticipantsRNs who: 1) worked directly with pediatric in-patients; 2) spoke English; 3) and who worked in rural Northern Ontario. Hospital sites were selected based on population density, from one province in Canada. To reduce heterogeneity, only sites with dedicated pediatric beds were eligible (n = 9). MethodsThis qualitative descriptive study used semi-structured interviews over Skype and telephone. Data were analyzed using inductive content analysis. ResultsTen participants were recruited from seven sites. Five main categories were identified, with one category that influenced all other categories. Rural RNs needed to practice as generalists as they care for many types of patients. Resource challenges included a lack of specialist expertise and educational opportunities. Pediatric pain was not perceived as a priority within their organizations. Most participants perceived there were no explicit standards for pain care. Moving forward the adoption of built in assessments in electronic documentation was suggested as a solution to standard pain care. ConclusionsOpportunity exists to improve pediatric pain management, however, without a systematic approach that considers the rural context, pain care for children will continue to be based on individual's beliefs and knowledge.

Family Experiences of Pediatric Inpatient Care in Alberta, Canada: Results From the Child HCAHPS Survey.

Patient experience surveys provide feedback regarding the perceived quality of health care services. Unfortunately, many surveys have tended to be focused on an adult population, resulting in a lack of validated instruments for pediatric populations. In 2015, Alberta Health Services implemented the Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) survey. Our objectives in the current study were to describe the use of the Child HCAHPS survey in Alberta, Canada, and to present preliminary results. Parents and/or guardians completed a modified version of the Child HCAHPS survey via telephone within 6 weeks of their child's discharge from 1 of 14 hospitals (2 stand-alone pediatric and 12 adult). For each of the survey composites and stand-alone items, the mean "top box" score is reported, reflecting the most positive response option. Overall results were reported, as were comparisons in top box scores between stand-alone pediatric and adult facilities. From October 2015 to March 2017, 3389 surveys were completed. Overall, mean top box scores ranged from 41.5% ("preventing mistakes and helping you report concerns") to 95.8% ("keeping you informed about your child's care in the emergency department"). Stand-alone pediatric hospitals tended to outperform the adult ones, particularly in global ratings of care, parental involvement in decision-making, and communication between parents and providers. With our findings, we indicate areas in which pediatric inpatient care is being delivered well, as well as targeted areas for quality improvement. Our results may be highlighted in future comparisons among others who have adopted the Child HCAHPS.