Pediatric Long-term Care Facilities Research Articles

Changes in Psychiatric Medication Use During the COVID-19 Pandemic in a Pediatric Long-Term Care Facility.

Background: Coronavirus disease 2019 (COVID-19) caused a global pandemic that dramatically altered infection control procedures in long-term care facilities. Mental health decline among residents of geriatric facilities during the pandemic has been described (Ferro Uriguen et al., 2022). Our study aims to evaluate psychological effects of the pandemic on residents of a pediatric long-term care facility, a population comprised of medically complex children. To characterize this, we compared patterns of psychotropic medication use during the COVID-19 pandemic to those of the prepandemic period among residents of a 76-bed pediatric long-term care facility. Methods: We conducted a retrospective study of psychotropic medication use from January 2019 to August 2022 using de-identified monthly facility medication refill data. Linear multivariable regression models were used to estimate the level and trends in the monthly rates of medication refills per 10,000 bed days among resident children before and after the pandemic onset. Six classes of psychotropic medications were analyzed including antipsychotics, antidepressants and anxiety medications, trazodone, clonidine, mood stabilizers, and gabapentin. Results: The pandemic onset was associated with a significant increase in the monthly prescribing rates of antidepressant and anxiety medications (20.83; 95% CI, 3.96-37.71; p = 0.017), mood stabilizers (10.44; 95% CI, 5.79-15.09; p < 0.001), and trazodone (-27.66; 95% CI, -40.44 to 14.88; p < 0.001) above those expected by prepandemic trends. The trend in trazodone use changed significantly during the pandemic from decreasing prepandemic to increasing (2.21; 95% CI, 1.28-3.14; p < 0.001). Antidepressant, anxiety medication, and gabapentin use increased throughout the study. Antidepressant and anxiety medication use surged early in the pandemic, but then continued growth at their prior rates of use. Discussion: Increased use of antidepressant and anxiety medications and trazodone suggests a possible impact of the COVID-19 pandemic on rates of anxiety, depression, sleep disturbance, and agitation among children with severe intellectual and developmental disabilities living in long-term care.

Medication Management Through Collaborative Practice for Children With Medical Complexity: A Prospective Case Series

OBJECTIVE Care coordination for children and youth with special health care needs and medical complexity (CYSHCN-CMC), especially medication management, is difficult for providers, parents/caregivers, and ­patients. This report describes the creation of a clinical pharmacotherapy practice in a pediatric long-term care facility (pLTCF), application of standard operating procedures to guide comprehensive medication management (CMM), and establishment of a collaborative practice agreement (CPA) to guide drug therapy. METHODS In a prospective case series, 102 patients characterized as CYSHCN-CMC were included in this pLTCF quality improvement project during a 9-month period. RESULTS Pharmacists identified, prevented, or resolved 1355 drug therapy problems (DTP) with an average of 13 interventions per patient. The patients averaged 9.5 complex chronic medical conditions with a ­median length of stay of 2815 days (7.7 years). The most common medications discontinued due to pharmacist assessment and recommendation included diphenhydramine, albuterol, sodium phosphate enema, ipratropium, and metoclopramide. The average number of medications per patient was reduced from 23 to 20. A pharmacoeconomic analysis of 244 of the interventions revealed a monthly direct cost savings of $44,304 ($434 per patient per month) and monthly cost avoidance of $48,835 ($479 per patient per month). Twenty-eight ED visits/admissions and 61 clinic and urgent care visits were avoided. Hospital ­readmissions were reduced by 44%. Pharmacist recommendations had a 98% acceptance rate. CONCLUSIONS Use of a CPA to conduct CMM in CYSHCN-CMC decreased medication burden, resolved, and prevented adverse events, reduced health care-related costs, reduced hospital readmissions and was well-accepted and implemented collaboratively with pLTCF providers.

Pediatric Long-Term Care Disaster and Pandemic Planning

Introduction:Children are frequently victims of disasters. However, significant gaps remain in pediatric disaster preparedness planning. This includes a lack of planning for pediatric residents in long-term care facilities. The New York City (NYC) Pediatric Disaster Coalition (PDC) is funded by the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) to improve NYC’s pediatric disaster preparedness and response. The NYC PDC partnered with experts in pediatric disaster management and the care of pediatric residents in long-term care facilities to create the Pediatric Long-Term Care Planning Committee (PLTCPC).Method:The PLTCPC included physicians, nurses, administrators, and emergency planning experts. The PLTCPC’s goal was to create guidelines and templates for use in disaster planning for pediatric residents at long-term care facilities. The committee met bi-weekly over three months and shared facility resources to create tools that meet the specific challenges presented by this population.Results:Utilizing an iterative process that included a literature review, participant presentations, review and improvement of the working documents, the final guidelines and templates for surge and evacuation of pediatric residents in long-term care facilities were created. Due to the onset of the COVID-19 pandemic, the NYC PDC reconvened the PLTCPC to focus on surge planning for pandemics at pediatric long-term care facilities. Two pediatric infectious disease clinicians were added to the committee. Utilizing the same process delineated above, a detailed pandemic specific annex was created based on clinical pediatric experience gained throughout the pandemic.Conclusion:To the authors' knowledge, these are the first pediatric-specific resources for long-term care disaster planning. They address the importance of matching resources to the unique needs of PLTC facilities, in regard to space, equipment, staffing, and training. Pediatric long-term care facilities present special needs during pandemics and this approach can be utilized as a model for other facilities.

Pediatric Outpatient, Urgent-care Emergency and Disaster Planning

Introduction:Children are frequently victims of disasters; however important gaps remain in pediatric disaster planning. This includes a lack of resources for pediatric preparedness planning for patients in outpatient/urgent-care facilities. The New York City Pediatric Disaster Coalition (NYCPDC) is funded by the NYC Department of Health and Mental Hygiene (DOHMH) to improve NYC’s pediatric disaster preparedness and response.After creating planning resources in Pediatric Long-Term Care Facilities, Hospital Pediatric Departments, Pediatric and Neonatal Intensive Care Units, and Obstetric/Newborn Services within NYC hospitals, the NYCPDC partnered with leaders and experts from outpatient/urgent-care facilities caring for pediatric patients and created the Pediatric Outpatient Disaster Planning Committee (PODPC). PODPC’s goal was to create guidelines and templates for use in disaster planning for pediatric patients at outpatient/urgent-care facilities.Method:The PODPC includes physicians, nurses, administrators and emergency planning experts who have experience working with outpatient facilities. There were 21 committee members from eight organizations (the NYCPDC, DOHMH, Community Healthcare Association of NY State, NY State DOH, NYC Health and Hospitals, Maimonides Medical Center and Presbyterian/Columbia University Medical Center). The committee met six times over a four-month period and shared information to create disaster planning tools that meet the specific pediatric challenges in the outpatient setting.Results:Utilizing an iterative process including literature review, participant presentations, discussions review and improvement of working documents, the final guidelines and templates for surge and evacuation of pediatric patients in outpatient/urgent care facilities were created in 2018. Subsequently model plans were completed and implemented at five NYC Outpatient/Urgent-care facilities.Conclusion:An expert committee utilizing an iterative process successfully created disaster guidelines and templates for pediatric outpatient/urgent care facilities. They addressed the importance of matching the special needs of children to available space, staff and equipment needs and created model plans for site-specific use.

A Comprehensive Coalition-Based Regional Approach to Pediatric Disaster Planning

Introduction:Children, who comprise 25% of the US population, are frequently victims of disasters and have special needs during these events. To prepare NYC for a large-scale Pediatric Disaster, NYCPDC has worked with an increasing number of providers that initially included only a small number of hospitals and agencies. Through a cooperative team approach, stakeholders now include local public health, emergency management and emergency medical services, 28 hospitals, community-based providers, and the Medical Reserve Corps.Method:The NYCPDC utilized an inclusive iterative process model whereby a desired plan was achieved by stakeholders reviewing the literature and current practice through repeated discussion and consensus building. NYCPDC used this model in developing a comprehensive regional pediatric disaster plan.Results:The plan included disaster scene triage (adapted for pediatric use) to transport (with prioritization) to surge and evacuation. Additionally, site-specific plans utilizing guidelines and templates now include Pediatric Long-Term Care Facilities, Hospital Pediatric Departments including Pediatric and Neonatal Intensive Care Services and Outpatient/Urgent Care Centers. A force multiplier course in critical care for non-intensivists has been provided. An extensive Pediatric Exercise program has been used to develop, operationalize and revise plans based on lessons learned. This initially included pediatric tabletop, functional and full-scale exercises at individual hospitals leading to citywide exercises at 13 and subsequently all 28 hospitals caring for children.Conclusion:The NYCPDC has comprehensively planned for the special needs of children during disasters utilizing a pediatric coalition based regional approach that matches pediatric resources to needs to provide best outcomes.The NYCPDC has responded to real time events (H1N1, Haiti Earthquake, Superstorm Sandy, Ebola), and participated in local (NYC boroughs and executive leadership) and nationwide coalitions (including the National Pediatric Disaster Coalition). The NYCPDC has had the opportunity to present their Pediatric Disaster Planning and Response efforts at local, national and International conferences.

Long-Term Care for Children With Medical Complexity: A Call for Data.

Long-Term Care for Children With Medical Complexity: A Call for Data.

COVID-19 and Vaccination for Residents and Staff in Pediatric Long-Term Care Facilities.

OBJECTIVES: Coronavirus disease 2019 (COVID-19) has had a significant impact on adult residents and staff in long-term care facilities. Little is known, however, about the impact of COVID-19 and the uptake of COVID-19 vaccination in pediatric long-term care facilities (pLTCFs). METHODS: A survey was designed, piloted, and e-mailed to facilities participating in the Pediatric Complex Care Association, an organization consisting of 43 pLTCFs. Respondents were sent 1 reminder and given 1 month (April 2021) to report retrospective data from March 2020 to March 2021. In the survey, pLTCFs were asked to report data on COVID-19 infections and outcomes among residents and staff as well as COVID-19 vaccination status among residents and staff. RESULTS: Twenty-five centers participated, representing a 56% survey response rate. Of the residents, 7.0% (117 cases) were infected with COVID-19. The proportion of residents with COVID-19 by site varied from 0% to 41%. Among staff members, 22% (1665 cases) were infected with COVID-19, with a range of 8% to 44% of staff by site. Of residents, 1.3% were transferred to acute care. There were 3 resident deaths and 4 staff deaths. Early uptake of COVID-19 vaccination was common for residents (76%), whereas for staff, the rate was lower at 62%. At individual pLTCFs, vaccination ranged from 5 to 83 residents and 46 to 499 staff. CONCLUSIONS: Pediatric residents and staff of long-term care facilities were impacted by COVID-19, but mortality was low. COVID-19 vaccination rates among the children and staff were similar and higher than that reported from early national data in skilled nursing facilities.

Children Are Not Small Adults

Playing a game of Candy Land with a tearful 12-year-old girl who lives in a pediatric long-term care facility (pLTCF) and has been isolated from her family at the onset of the COVID-19 pandemic, I consider the fact that protecting my patient from COVID-19 infection requires isolating her from her loved ones. An epic poem comes to mind. Homer’s Odyssey describes the plight of Odysseus and his perilous journey returning to his home kingdom of Ithaca. Due to uncontrollable circumstances including war and captivity, Odysseus is kept from his beloved homeland for years. On his eventual sea journey home he must sail between two sea monsters found on opposite sides of a narrow straight: the perilous whirlpool Charybdis and the six headed monster Scylla. As there is no escape without cost, Odysseus is forced to choose the lesser of the two evils; passing by Scylla, losing only a few sailors rather than risking the loss of his entire ship in the whirlpool. As a medical student rotating in a pLTCF at the onset of the pandemic, I recall many instances where physicians and facility leaders were forced to choose between the lesser of two evils while creating policies and best practices for resident children. Balancing the creation of an effective infection control policy with the negative effects of social isolation on resident children demonstrates one example: My patient was sad during the initial weeks of isolation from her family. Now, a year later and still isolated, I wonder if she and her family think that facility policies implemented to prevent COVID-19 infection have been worth the sacrifice.

Active surveillance for acute respiratory infections among pediatric long-term care facility staff

Transmission of respiratory viruses between staff and residents of pediatric long-term care facilities (pLTCFs) can occur. We assessed the feasibility of using text or email messages to perform surveillance for acute respiratory infections (ARIs) among staff. From December 7, 2016 to May 7, 2017, 50 staff participants from 2 pLTCFs received weekly text or email requests to report the presence or absence of ARI symptoms. Those who fulfilled the ARI case definition (≥2 symptoms) had respiratory specimens collected to detect viruses by reverse transcriptase polymerase chain reaction assays. Pre- and postsurveillance respiratory specimens were collected to assess subclinical viral shedding. The response rate to weekly electronic messages was 93%. Twenty-one ARIs reported from 20 (40%) participants fulfilled the case definition. Respiratory viruses were detected in 29% (5/17) of specimens collected at symptom onset (influenza B, respiratory syncytial virus, coronavirus [CoV] 229E, rhinovirus [RV], and dual detection of CoV OC43 and bocavirus). Four participants had positive presurveillance (4 RV), and 6 had positive postsurveillance specimens (3 RV, 2 CoV NL63, and 1 adenovirus). Electronic messaging to conduct ARI surveillance among pLTCF staff was feasible.

Knowledge, Attitudes, and Practices of Pediatric Long-term Care Facility Staff Regarding Infection Control for Acute Respiratory Infections and Influenza Vaccination

We surveyed clinical staff and on-site teachers working at pediatric long-term care facilities regarding prevention and control of acute respiratory infections and influenza in staff and residents. We uncovered knowledge gaps, particularly among teachers and clinical staff working <5 years at sites, thereby elucidating areas for targeted staff education.

Infection prevention and control and antibiotic stewardship practices in pediatric long-term care facilities.

Pediatric long-term care facilities were surveyed to assess infection control and antimicrobial stewardship practices. Policies mandated by the Centers of Medicare and Medicaid Services (CMS) were included. Only 40% of sites reported implementing >90% of surveyed CMS policies. The survey also identified several gaps in non-CMS-mandated policies.

Pediatric Outpatient/Urgent-Care Emergency and Disaster Planning

Introduction:Children are frequently victims of disasters, however important gaps remain in pediatric disaster planning. This includes a lack of resources for pediatric preparedness planning for patients in outpatient/urgent-care facilities. The New York City Pediatric Disaster Coalition (NYCPDC) is funded by the NYC Department of Health and Mental Hygiene (DOHMH) to improve NYC’s pediatric disaster preparedness and response.Aim:After creating planning resources in Pediatric Long-Term Care Facilities, Hospital Pediatric Departments, Pediatric and Neonatal Intensive Care Units and Obstetric/Newborn Services within NYC hospitals, the NYCPDC partnered with leaders and experts from outpatient/urgent-care facilities caring for pediatric patients and created the Pediatric Outpatient Disaster Planning Committee (PODPC). PODPC’s goal was to create guidelines and templates for use in disaster planning for pediatric patients at outpatient/urgent-care facilities.Methods:The PODPC includes physicians, nurses, administrators, and emergency planning experts who have experience working with outpatient facilities. There were 21 committee members from eight organizations (the NYCPDC, DOHMH, Community Healthcare Association of NY State, NY State DOH, NYC Health and Hospitals, Maimonides Medical Center and Presbyterian/Columbia University Medical Center). The committee met six times over a four-month period and shared information to create disaster planning tools that meet the specific pediatric challenges in the outpatient setting.Results:Utilizing an iterative process including literature review, participant presentations, discussions review, and improvement of working documents, the final guidelines and templates for surge and evacuation of pediatric patients in outpatient/urgent care facilities were created in February 2018. Subsequently, model plans were completed and implemented at five NYC outpatient/urgent-care facilities.Discussion:An expert committee utilizing an iterative process successfully created disaster guidelines and templates for pediatric outpatient/urgent care facilities. They addressed the importance of matching the special needs of children to available space, staff, and equipment needs and created model plans for site-specific use.

A Comprehensive Coalition Based Regional Approach to Pediatric Disaster Planning

Introduction:Children, who comprise 25% of the US population, are frequently victims of disasters and have special needs during these events.Aim:To prepare NYC for a large-scale pediatric disaster, NYCPDC has worked with an increasing number of providers that initially included a small number of hospitals and agencies. Through a cooperative team approach, stakeholders now include public health, emergency management, and emergency medical services, 28 hospitals, community-based providers, and the Medical Reserve Corps.Methods:The NYCPDC utilized an inclusive iterative process model whereby a desired plan was achieved by stakeholders reviewing the literature and current practice through discussion and consensus building. NYCPDC used this model in developing a comprehensive regional pediatric disaster plan.Results:The Plan included disaster scene triage (adapted for pediatric use) to transport (with prioritization) to surge and evacuation. Additionally, site-specific plans utilizing Guidelines and Templates now include Pediatric Long-Term Care Facilities, Hospital Pediatric Departments, Pediatric and Ob/Newborn/Neonatal Intensive Care Services and Outpatient/Urgent Care Centers. A force multiplier course in critical care for non-intensivists is provided. An extensive Pediatric Exercise program has been used to develop, operationalize and revise plans based on lessons learned. This includes pediatric tabletop, functional and full-scale exercises at individual hospitals leading to citywide exercises at 13 and subsequently all 28 hospitals caring for children.Discussion:The NYCPDC has comprehensively planned for the special needs of children during disasters utilizing a pediatric coalition based regional approach that matches pediatric resources to needs to provide best outcomes.The NYCPDC has responded to real-time events (H1N1, Haiti Earthquake, Superstorm Sandy, Ebola), and participated in local (NYC boroughs and executive leadership) and nationwide coalitions (National Pediatric Disaster Coalition). The NYCPDC has had the opportunity to present their Pediatric Disaster Planning and Response efforts at local, national and International conferences.

1245. Infection Prevention and Control (IP&amp;C) and Antibiotic Stewardship (AS) Practices in Pediatric Long-Term Care Facilities

BackgroundIn November 2017, the Centers for Medicare and Medicaid (CMS) implemented a requirement for long-term care facilities (LTCFs) to incorporate AS into their IP&C programs. The purpose of this study was to describe baseline IP&C and AS practices in pediatric LTCFs.MethodsWe modified a survey from the CDC to assess IP&C in pediatric LTCFs. The internet-based survey was distributed to the 41 pLTCFs in the Pediatric Complex Care Association from May to June 2017. The 67-question survey included questions to assess IP&C domains and infrastructure such as written policies, hand and respiratory hygiene (HH), personal protective equipment (PPE) use, environmental cleaning, and AS practices. Responses to questions were summarized using frequencies and analyzed using χ2 or Fisher’s exact tests, as appropriate. The characteristics of sites with ≥90% compliance with the CMS rule, as assessed by 14 relevant survey questions, were compared with those of sites with <90% compliance.ResultsOverall, 25 (61%) facilities nationwide completed the survey. All sites reported having written IP&C policies and most had a person responsible for IP&C (96%); fewer reported reviewing/updating these policies annually (72%). Few sites provided feedback to staff on HH adherence (44%), PPE use (40%), and cleaning/disinfection procedures (44%). Few had written policies on antibiotic prescribing (48%) or provided prescribers with feedback about their prescribing practices (40%). Sites with ≥90% compliance with the CMS rule were more likely to report providing prescribers with feedback (70% vs. 20%, P = 0.03), to have provided AS training to clinical (60% vs. 0%, P < 0.01) and nursing staff (70% vs. 7%, P < 0.01) in the past 12 months, and to provide feedback regarding HH (70% vs. 27%, P = 0.05).ConclusionWhile most facilities had implemented some IP&C and AS strategies pertaining to the CMS rule before its enforcement, this survey identified several gaps, especially pertaining to staff feedback for IP&C practices and antibiotic prescribing. Facilities should develop feedback strategies and regularly reinforce the importance of IP&C at employment and during regular trainings.Disclosures All authors: No reported disclosures.

Family Experiences and Perspectives on Infection Prevention in Pediatric Long-Term Care.

Residents of pediatric long-term care facilities (pLTCF) are particularly vulnerable to healthcare-associated infections. The aims of this qualitative study were to (a) explore perspectives on infection prevention among families visiting children in pLTCF and (b) identify facilitators of and barriers to optimal hand hygiene. Semistructured, in-depth interviews with 10 family members visiting two New York City metropolitan area facilities were analyzed to identify themes. "Everyone follows the rules" and "infections are inevitable" were primary themes. Participants reported "common sense" as a facilitator and "distraction" as a major barrier to prevention practices. Current education for visitors may be inadequate to improve infection prevention behaviors. Nurse-led education strategies for infection prevention should be tested and modified for families visiting pLTCF.

The effect of ultraviolet-C technology on viral infection incidence in a pediatric long-term care facility

Ultraviolet-C (UV-C) technology implementation was associated with a 44% reduction in viral infection incidence among pediatric patients in a long-term care facility (incidence rate ratio, 0.56; 95% confidence interval, 0.37-0.84; P=.003). UV-C was included as an adjunct to standard cleaning protocols over a 12-month period; no other new interventions were introduced during this time. The results suggest that UV-C technology is a potentially important component of eliminating the environment as a source of viral infections.

Associations Between Enteral Nutrition and Acute Respiratory Infection Among Patients in New York Metropolitan Region Pediatric Long-Term Care Facilities.

Pediatric long-term care facilities (pLTCF) serve a complicated and resource-intensive patient population with high usage of nutrition support. However, the relationship between nutrition support and outcomes among pLTCF residents is not well understood. We described this relationship in three metropolitan New York pLTCF and a subsample of infants from one of these facilities with a feeding disorders unit. In this prospective cohort study, we used logistic regression to assess relationships between enteral nutrition (EN), and acute respiratory infections (ARI) among residents (n = 720, 50% male, mean age = 5.5 years, mean number comorbidities = 2.1) and infant subsample (<1 year, n = 208, 50% male, mean number comorbidities = 2.0). We tested these associations in multivariable models controlling for numbers of comorbidities and infections. Many residents received nutrition via percutaneous (59%) or nasogastric (15%) feeding tubes. In univariate analyses, residents receiving EN had more comorbidities. In multivariable analyses, EN was associated with ARI (incidence rate ratio = 1.65, p < .001). Among infants in the specialized unit, greater risk of ARI was associated only with percutaneous (incidence rate ratio = 1.94, p < .01) feeding. EN was associated with lower odds of being discharged home (OR = 0.45, p < .01). The prevalence of EN, complexity of cases, and necessity of long-term EN make nutrition support important in pLTCFs. Differences in EN types and adverse outcomes in the infant subsample suggest different care is necessary for this subpopulation. Results provide context for improving quality of care and clinician/caregiver education for this population.

National Testing of the Nursing-Kids Intensity of Care Survey for Pediatric Long-term Care

PurposeThe purpose of this study is to test the Nursing–Kids Intensity of Care, a measure of the intensity of nursing care needs, defined as the quantity and type of direct and indirect care activities performed by caregivers in a national sample. Design and MethodsA 40-item tool previously tested in a small sample was psychometrically tested on a sample of 116 children with complex medical conditions by 33 nurse raters across 11 pediatric sites. ResultsThe Nursing-Kids Intensity of Care tool demonstrated components of usability, feasibility, inter-rater, test-retest and internal consistency reliability and construct validity in the national study sample. ConclusionsAdditional testing to further establish psychometric sufficiency and expanded use to quantify the intensity of nursing care needs of children with complex medical conditions in pediatric long-term care settings is recommended. Practice ImplicationsThis novel measure could assist the nursing administrators, educators and staff of pediatric long-term care facilities assess the intensity of care needs of their residents.

Incidence, Risks, and Types of Infections in Pediatric Long-term Care Facilities

The population of infants, children, and adolescents cared for at pediatric long-term care facilities is increasing in complexity and size and thus consumes substantial health care resources. Infections are a significant cause of morbidity and mortality in this population, but few recent data describe their incidence and effects. To describe the types of infections diagnosed in residents of pediatric long-term care facilities, calculate infection rates, and identify risk factors for respiratory tract infections (RTIs). This prospective cohort study, which was part of a larger trial called Keep It Clean for Kids, was conducted from September 1, 2012, to December 31, 2015, at 3 pediatric long-term care facilities in New York. Residents of the facilities who were 21 years or younger and either residents or admitted during the study period (n = 717) were enrolled in the study. Medical records were reviewed to identify infections diagnosed by site clinicians. Incidence of infections, such as RTIs; skin and soft-tissue infections; chronic comorbid conditions, including neurologic and respiratory disorders; and device use, including gastrostomy tubes and tracheostomies, was determined. Risk factors for RTIs were assessed by generalized linear mixed method regression modeling. The 717 residents had a median (interquartile range) age at enrollment of 2.6 (0.4-9.1) years; 358 (49.9%) were male. Four hundred twenty-eight residents (59.7%) had feeding tubes and 215 (30.0%) had tracheostomies. Most chronic comorbid conditions were musculoskeletal or ambulation (532 residents [74.2%]), neurologic (505 [70.4%]), respiratory (361 [50.3%]), and gastrointestinal (230 [32.1%]) disorders, and 460 residents (64.2%) had 4 or more chronic comorbid conditions. Site clinicians diagnosed 2052 infections during the 3-year study period. Respiratory tract infections were most common and were diagnosed in 1291 residents (62.9%). The overall infection rate was 5.3 infections per 1000 resident-days, and RTI rates were 3.3 infections per 1000 resident-days. Overall infection rates and rates of RTI, skin and soft-tissue infection, urinary tract infection, and bloodstream infection varied among the 3 sites. In the multivariable model, younger age (incidence rate ratio [IRR], 1.05; 95% CI, 1.03-1.06), increased number of chronic comorbid conditions (IRR, 1.12; 95% CI, 1.06-1.19), and the use of feeding tubes (IRR, 1.34; 95% CI, 1.03-1.64) and tracheostomies (IRR, 1.40; 95% CI, 1.17-1.69) were associated with RTIs. In this study, RTIs were the most common infections diagnosed, but modifiable risk factors for RTIs were not identified. Future work should focus on optimizing infection prevention and control strategies to reduce infections, particularly RTIs, in the pediatric long-term care population.

Patient Safety Culture Survey in Pediatric Complex Care Settings: A Factor Analysis.

Children with complex medical needs are increasing in number and demanding the services of pediatric long-term care facilities (pLTC), which require a focus on patient safety culture (PSC). However, no tool to measure PSC has been tested in this unique hybrid acute care-residential setting. The objective of this study was to evaluate the psychometric properties of the Nursing Home Survey on Patient Safety Culture tool slightly modified for use in the pLTC setting. Factor analyses were performed on data collected from 239 staff at 3 pLTC in 2012. Items were screened by principal axis factoring, and the original structure was tested using confirmatory factor analysis. Exploratory factor analysis was conducted to identify the best model fit for the pLTC data, and factor reliability was assessed by Cronbach alpha. The extracted, rotated factor solution suggested items in 4 (staffing, nonpunitive response to mistakes, communication openness, and organizational learning) of the original 12 dimensions may not be a good fit for this population. Nevertheless, in the pLTC setting, both the original and the modified factor solutions demonstrated similar reliabilities to the published consistencies of the survey when tested in adult nursing homes and the items factored nearly identically as theorized. This study demonstrates that the Nursing Home Survey on Patient Safety Culture with minimal modification may be an appropriate instrument to measure PSC in pLTC settings. Additional psychometric testing is recommended to further validate the use of this instrument in this setting, including examining the relationship to safety outcomes. Increased use will yield data for benchmarking purposes across these specialized settings to inform frontline workers and organizational leaders of areas of strength and opportunity for improvement.