Pediatric Inpatient Ward Research Articles

Causes, reporting, and prevention of medication errors from a pediatric nurse perspective

Objective: The aim of this study was to determine the perspective of pediatric nurses regarding the causes, reporting, and prevention of medication errors. Design: A descriptive, cross‑sectional study. Setting: Nurses were selected from inpatient pediatric wards of 4 hospitals in Turkey. Subjects: 119 pediatric nurses agreed to participate in the research and completed semi‑structured questionnaires. These data were collected and analyzed. The average age of the nurses was 24.7 ± 3.58 years; the majority was women (96.6%). Results: Pediatric nurses stated that the most common causes of medication errors were long work hours (68.1%) and a high patient/nurse ratio (58.8%). Although the majority of nurses (88%) made use of a medication error notification system, many errors were not reported and nurses cited potential blaming of nurses in case of adverse outcome for the patient (52.95%), loss of trust (50.45%), and fear of disciplinary proceedings (42%) among the causes of lack of notification. With regard to avoidance, nurses most commonly cited the need for adequate information regarding the safe use of medications (45.4%). Conclusions: This is the first study in Turkey to address the pediatric nurse perspective regarding medication errors. The results argue that there is a need for ongoing training of pediatric nurses concerning safe medication administration and that the causes and underreporting of medication errors warrant further investigation.

Body weight predicts spinal canal depth in general paediatric population

Aims Samples of cerebrospinal fluid (CSF) are required for the management of many disease states. One of the commonest errors in performing lumbar punctures (LPs) is inaccurate insertion of the spinal needle (too shallow or too deep), with blood contamination often complicating subsequent laboratory interpretation. We previously demonstrated a good correlation between ultrasound measures of spinal canal depth (SCD) and body weight in neonates, producing a nomogram (1) which has been tested in clinical practice (2). Here, we present preliminary data from ultrasound and auxological assessment in an older general paediatric population. Other studies have been limited by small cohort size, measurements being taken in the supine position during CT, or data gathered post-LP procedure, based on recall of depth of needle insertion. Methods Single-centre study of patients aged 0–18 years presenting at a tertiary paediatric centre. Patients were recruited from cardiology outpatients, PICU and paediatric inpatient wards. Individuals with pre-existing spinal abnormalities were excluded. Ultrasound measures of the spinal canal were performed in the left lateral position to obtain anterior and posterior SCDs; from these measures the mid-SCD (MSCD) was calculated. Patient age and auxological parameters including patient weight, height and body surface area (BSA) were recorded. Results 125 children were recruited and had complete data recorded (figure 1). The median age of the study population was 7.0 years (range 0.3-16.0). All auxological data are presented as means (standard deviation; range). Weight was 30.6 kgs (16.1; 7.8-88.9) and height 128 cms (29.1; 67.9-179.6), resulting in a mean BSA of 1.03 m 2 (0.39; 0.35-1.88). We identified a linear correlation between MSCD (mm) and age (R2 0.68), weight (R2 0.79), height (R2 0.74) and BSA (R2 0.79). The approximated formula for predicting MSCD from body weight (W Kg) in this cohort is MSCD (mm) = 0.4W + 20 (figure 1). Conclusion Our preliminary data demonstrates good correlation between both patient weight and BSA and MSCD in an unselected older general paediatric population. The most practical MSCD correlation is likely to be that based on weight, as height is infrequently routinely measured in clinical practice. This needs testing in clinical practice.

Nurse practitioner led short stay assessment units: an alternative model of care?

Aim The UK is undergoing a major reconfiguration of inpatient paediatric services. Recent guidelines encourage the development of short stay assessment units to increase patient/parent satisfaction and reduce burden on inpatient care. We wish to evaluate a novel 24-hour assessment unit whereby Paediatric Nurse Practitioners (PNPs) take the lead role in assessment and management with additional support provided by doctors. Methods A prospective observational study of acute attendances to this short-stay assessment unit over four data collection periods was performed. Each period lasted one month and each season was included. Outcomes evaluated included: reason for attendance, length of stay, discharges, transfers to the offsite inpatient paediatric ward and re-attendance rates. Results 270 acute attendances (mean age of 5 years, 23% Conclusion The data analysed are comparable to standard doctor-led units reported in the literature and would suggest that this model of care, with appropriate doctor involvement, could be a safe option for a short stay paediatric assessment unit. However to further determine the viability of such a unit, further research is recommended to ascertain cost-effectiveness and parent/staff satisfaction.

How Do We Talk To Our Children?: Using Child Life To Support the Children of Seriously Ill Adult Inpatients (789)

1.Understand the role of child life in supporting the children of seriously ill adult patients.2.List resources available to support the children of seriously ill adult patients.3.Understand how to integrate child life into an existing inpatient palliative care service. Families with children struggle with how to talk about and cope with a parent’s life-threatening illness, yet open communication can reduce anxiety, depression, and other psychobehavioral problems in these children before and after their parent’s death. Clinicians of many disciplines who are trained in adult medicine may not be prepared to address these issues. Child life specialists traditionally fill this role in inpatient pediatric wards but are rarely used in adult settings. We reviewed the literature on the role of child life specialists in the care of children of adults with serious illness and report our experience with developing a consultation service to provide this support. Results. Although extensive data support child life interventions in the pediatric setting, no studies report the impact of child life specialists in the care of children of adults with serious illness. At our academic medical center a child life specialist met with the families of over 90 inpatient parents with serious illness, facilitating communication with and providing support for their children to improve coping, processing, and self-expression in a developmentally appropriate manner. Support and education were also provided to the staff caring for these patients. Barriers to setting up a similar program include lack of access to child life services, institutional separation between pediatric and adult services, and resistance to a new role in the palliative care team. Medical centers without access to child life services can still develop resources to help clinicians and families. Child life specialists are uniquely prepared to address the acute needs of children in families with a hospitalized seriously ill parent. Institutions with access to child life specialists should consider employing them in the adult setting. More research is needed to evaluate the clinical impact of such services.

Missed immunisation opportunities in emergency departments in northern New South Wales, Australia

The aim of this study was to determine the proportion of children less than 12 months of age presenting to Hunter New England (HNE) emergency departments (EDs) during 2009 who were overdue for immunisations and identify factors associated with overdue status. The immunisation status of all children aged between 3 months and 1 year (120-365 days) who presented at an HNE ED between 1 January and 31 December 2009 was determined using Australian Childhood Immunisation Register (ACIR) 30-day overdue reports. The ED dataset and ACIR reports were linked using a deterministic method. Six per cent (253/4218) of children who attended an HNE ED in 2009 were overdue for immunisation and 28.1% (71/253) presented multiple times while overdue. There was a median delay of 77 days from their first presentation while overdue until they no longer appeared on the ACIR 30-day overdue report. Children who presented while overdue were more likely to present multiple times to EDs (RR = 1.45; P = 0.0025), be in a life-threatening triage category (P = 0.012) and present at tertiary referral hospitals (P < 0.001). Important missed immunisation opportunities occurred in HNE EDs and may occur in other EDs in Australia. Half of the children who presented to Hunter New England emergency departments while overdue for immunisation remained overdue for greater than 77 days following their presentation. Opportunities exist in EDs and paediatric inpatient wards for ensuring that all children are protected against vaccine-preventable diseases.

Parent Understanding of the Role of Doctors and Doctors in Training on an Inpatient Pediatric Ward

Background: Many physician trainees care for patients in an academic hospital. We studied parent understanding of the roles of medical students, interns, residents, and attending physicians in the inpatient setting of a children's hospital. Description: Surveys were given to parents during a hospital stay on a medical service asking about the responsibilities and education of physicians and trainees. Evaluation: The majority of respondents knew that medical students were not doctors, could not write prescriptions, or supervise residents or attendings. Most respondents did not know that an intern had completed medical school, was a doctor, or could write prescriptions. Most respondents knew that attendings had graduated from medical school, were doctors, and supervise interns and students. Factors affecting understanding of these roles included the parent's level of education and race. Conclusion: Confusion exists about the different roles of physicians and trainees, particularly in parents without a college education, and who self-identify as non-White.

Implementing the Bedside Paediatric Early Warning System in a community hospital: A prospective observational study

Late transfer of children with critical illness from community hospitals undermines the advantages of community-based care. It was hypothesized that implementation of the Bedside Paediatric Early Warning System (Bedside PEWS) would reduce late transfers. A prospective before-and-after study was performed in a community hospital 22-bed inpatient paediatric ward. The primary outcome, significant clinical deterioration, was a composite measure of circulatory and respiratory support before transfer. Secondary outcomes were stat calls and resuscitation team calls, paediatrician workload and perceptions of frontline staff. Care was evaluated for 842 patient-days before and 2350 patient-days after implementation. The median inpatient census was 13. Implementation of the Bedside PEWS was associated with fewer stat calls to paediatricians (22.6 versus 5.1 per 1000 patient-days; P<0.0001), fewer significant clinical deterioration events (2.4 versus 0.43 per 1000 patient-days; P=0.013), reduced apprehension when calling the physician and no change in paediatrician workload. Implementation of the Bedside PEWS is feasible and safe, and may improve clinical outcomes.

Acute Renal Replacement Therapy in Children with Diarrhea-Associated Hemolytic Uremic Syndrome: A Single Center 16 Years of Experience

Acute kidney injury (AKI) is becoming more prevalent among hospitalized children, its etiologies are shifting, and new treatment modalities are evolving; however, diarrhea-associated hemolytic uremic syndrome (D+HUS) remains the most common primary disease causing AKI in young children. Little has been published about acute renal replacement therapy (ARRT) and its challenges in this population. We describe our single center's experience managing 134 pediatric patients with D+HUS out of whom 58 (43%) required ARRT over the past 16 years. In our cohort, all but one patient were started on peritoneal dialysis (PD). Most patients, 47 (81%), received acute PD on a pediatric inpatient ward. The most common recorded complications in our cohort were peritoneal fluid leaks 13 (22%), peritonitis 11 (20%), and catheter malfunction 5 (9%). Nine patients (16%) needed surgical revision of their PD catheters. There were no bleeding events related to PD despite a mean platelets count of 40.9 (±23.5) × 103/mm3 and rare use of platelets infusions. Despite its methodological limitations, this paper adds to the limited body of evidence supporting the use of acute PD as the primary ARRT modality in children with D+HUS.

Routine and adaptive expert strategies for resolving ICT mediated communication problems in the team setting

The use of information and communication technologies (ICTs) for supporting interprofessional communication is becoming increasingly common in health care. However, little research has explored how ICTs affect interprofessional communication, or how novices are trained to be effective interprofessional ICT users. This study explores the interprofessional communication strategies of nurses and doctors (trainees and experts) when their communications were mediated by a specific ICT: an electronic patient record (EPR). A total of 72 doctors and nurses participated in this 8-month study on a paediatric in-patient ward. Eighty hours of non-participant observations and 20 semi-structured interviews were conducted. All data were rendered anonymous prior to analysis. Using a constructivist grounded theory approach, one researcher read and analysed all data recursively. As emergent themes were identified, exemplary portions of the data were discussed with three additional researchers to resolve discrepancies and confirm the coding structure. Expertise literatures informed the final analyses. Three interprofessional communication strategies were identified: (i) all participants routinely formulated 'workarounds' to circumvent problematic EPR-mediated communications; (ii) workarounds were classifiable as instances of Abandoning, Forcing or Submitting to the EPR, and (iii) novices learned workaround strategies through an informal curriculum, but they did not learn to manage the interprofessional effects of these workarounds. Trainees relied on workarounds as simplified routines, demonstrating routine expertise. Staff members, demonstrating adaptive expertise, used workarounds as part of a broader network of people and communication tools. Explicit training regarding this network and the ways in which workarounds conceal this network may help trainees develop adaptive expertise.

Family-centered Multidisciplinary Rounds Enhance the Team Approach in Pediatrics

The objective of this study was to determine the impact of family-centered multidisciplinary rounds on an inpatient pediatric ward. We hoped to (1) gain a better understanding of the patient and family experience with family-centered multidisciplinary rounds, (2) measure hospital staff satisfaction with family-centered multidisciplinary rounds compared with conventional rounds, and (3) understand the time commitment for family-centered multidisciplinary rounds and conventional rounds. A quasi-experimental design was undertaken during a 2-week period. During the first week, the hospital staff conducted conventional rounds. Families were surveyed daily, and the staff were surveyed at the end of the week regarding their experiences. During the second week, newly admitted patients received family-centered multidisciplinary rounds at the bedside. Again, both families and staff were surveyed. Observers recorded the interactions between families and staff and measured the time required to conduct rounds. A total of 27 patients were admitted during the 2-week study period. No significant differences were found in family satisfaction between conventional rounds and family-centered multidisciplinary rounds. A total of 53 surveys were collected from staff members. The staff reported better understanding of the patients' medical plans, better ability to help the families, and a greater sense of teamwork with family-centered multidisciplinary rounds compared with conventional rounds. It required an additional 2.7 minutes per patient during rounds for family-centered multidisciplinary rounds. With family-centered multidisciplinary rounds, the family affected the medical decision-making discussion in 90% of cases. Family-centered multidisciplinary rounds is a method of conducting inpatient hospital rounds that fosters teamwork and empowers hospital staff. The patient and family are engaged in and are the focal point of the rounds. Staff members are able to hear everyone's perspective and give input. The impact on staff satisfaction and the family's ability to participate in their care is significant.

Effect of Computer Order Entry on Prevention of Serious Medication Errors in Hospitalized Children

Although initial research suggests that computerized physician order entry reduces pediatric medication errors, no comprehensive error surveillance studies have evaluated the effect of computerized physician order entry on children. Our objective was to evaluate comprehensively the effect of computerized physician order entry on the rate of inpatient pediatric medication errors. Using interrupted time-series regression analysis, we reviewed all charts, orders, and incident reports for 40 admissions per month to the NICU, PICU, and inpatient pediatric wards for 7 months before and 9 months after implementation of commercial computerized physician order entry in a general hospital. Nurse data extractors, who were unaware of study objectives, used an established error surveillance method to detect possible errors. Two physicians who were unaware of when the possible error occurred rated each possible error. In 627 pediatric admissions, with 12,672 medication orders written over 3234 patient-days, 156 medication errors were detected, including 70 nonintercepted serious medication errors (22/1000 patient-days). Twenty-three errors resulted in patient injury (7/1000 patient-days). In time-series analysis, there was a 7% decrease in level of the rates of nonintercepted serious medication errors. There was no change in the rate of injuries as a result of error after computerized physician order entry implementation. The rate of nonintercepted serious medication errors in this pediatric population was reduced by 7% after the introduction of a commercial computerized physician order entry system, much less than previously reported for adults, and there was no change in the rate of injuries as a result of error. Several human-machine interface problems, particularly surrounding selection and dosing of pediatric medications, were identified. Additional refinements could lead to greater effects on error rates.

Pediatric emergency medicine: a world of potential

Pediatric emergency medicine (PEM) is a mature discipline in North America, although it does not exist, or is still in its infancy, in many regions of the world. Maturity arrives with expectations, which, if unfulfilled, are likely to result in unrealized potential and indeed early senility. PEM practitioners need to consider what is expected of the discipline to achieve full potential. A myopic outlook leads one to believe that PEM entails taking care of children in the pediatric emergency department (PED). Working in a PED has its challenges, with limited resources and increased demands. Inpatient bed shortages, curtailed laboratory services, inadequate staff and large patient volumes place tremendous stress on the PED in its role of triaging, treating and ensuring that every child gets appropriate care. Yet the PED is an integral part of the hospital system and works closely with the pediatric intensive care unit (ICU), pediatric inpatient wards and operating rooms to ensure a seamless interface to other pediatric subspecialties. Many of the procedures that were once the realm of specialty services are now performed in the emergency department (ED). Procedures such as endotracheal intubation and procedural sedation that were facilitated by anesthesiologists are now an integral part of the PED capability. Stabilization and skilled resuscitation, once the domain of specialized intensivists, are now managed equally well in the ED by PEM-trained physicians. Suturing lacerations and reducing closed fractures are now routine for pediatric emergentologists. The importance of having the PED work closely with the pediatric ICU and the rest of the hospital has been previously emphasized. 1

Use of a Web-based Tool to Enhance Medical Student Learning in the Pediatric Intensive Care Unit and Inpatient Wards

Use of a Web-based Tool to Enhance Medical Student Learning in the Pediatric Intensive Care Unit and Inpatient Wards

Communication of randomization in childhood leukemia trials.

Most children diagnosed as having leukemia become research subjects in randomized clinical trials (RCTs), but little is known about how randomization is explained to or understood by parents. To investigate physicians' explanation and parental understanding of randomization in childhood leukemia RCTs. A multisite study of the informed consent communication process for RCTs of childhood leukemia. Consecutive cases were recruited from pediatric oncology inpatient wards at 6 US children's hospitals associated with major academic medical centers from July 1, 1999, until December 31, 2001. The informed consent conferences were observed and audiotaped, and the information obtained was coded and analyzed. Parents were interviewed shortly after the conference to ascertain their understanding. Parents and members of the health care team who participated in 137 informed consent conferences for children with newly diagnosed acute leukemia. Observed explanations of randomization and parental understanding of randomization after the consent conference. Randomization was explained by physicians in 83% of cases and a consent document was presented during the conference in 95% of cases. Interviews after the conference demonstrated that 68 (50%) of 137 parents did not understand randomization. Parents of racial minority and lower socioeconomic status were less likely to understand randomization (P<.001 for each). Discussion of specific clinical trial details and the presence of a nurse during the conference were associated with understanding. Eighty-four percent of children were enrolled in a leukemia trial. Despite oral and written explanation, half of the parents in this study did not understand randomization for childhood leukemia trials. To make informed consent more effective, future research must seek to improve communication during this critical interchange.

Pediatric education in emergency medicine residency programs—10 years later

The purpose of this study is to examine the changes in the pediatric emergency medicine education of emergency medicine (EM) residents over the last decade. Questionnaires were mailed to the training directors of all EM residency programs. Sixty-five programs (79%) responded. While children represent 29 +/- 2% of all patients seen in the institutions surveyed, only 17 programs (26%) provide more than six months of pediatric education, ie, no increase in the last decade. EM residents frequently rotate through pediatric emergency departments (72%), inpatient pediatric wards (51%), and pediatric intensive care units (88%). Most physicians in charge of pediatric emergency medicine education are emergency medicine trained (75% vs 29% in 1981), and only 12% are pediatric emergency medicine fellowship trained. Despite several improvements and the increased satisfaction of program directors, the pediatric component of EM residents' training continues to be disproportionate to the number of children in the emergency medicine patient population. Specialists in pediatric emergency medicine should strive to play a more significant role in the pediatric education of EM residents.