Quaternary Hospital Research Articles

Benchmarking nanopore sequencing and rapid genomics feasibility: validation at a quaternary hospital in New Zealand

Approximately 200 critically ill infants and children in New Zealand are in high-dependency care, many suspected of having genetic conditions, requiring scalable genomic testing. We adopted an acute care genomics protocol from an accredited laboratory and established a clinical pipeline using Oxford Nanopore Technologies PromethION 2 solo system and Fabric GEM™ software. Benchmarking of the pipeline was performed using Global Alliance for Genomics and Health benchmarking tools and Genome in a Bottle samples (HG002-HG007). Evaluation of single nucleotide variants resulted in a precision and recall of 0.997 and 0.992, respectively. Small indel identification approached a precision of 0.922 and recall of 0.838. Large genomic variations from Coriell Copy Number Variation Reference Panel 1 were reliably detected with ~2 M long reads. Finally, we present results obtained from fourteen trio samples, ten of which were processed in parallel with a clinically accredited short-read rapid genomic testing pipeline (Newborn Genomics Programme; NCT06081075; 2023-10-12).

Postpartum Acute Care Utilization in a Health Care System in the Southeastern United States.

Introduction: Postpartum acute care utilization (PACU), including visits to an emergency department, obstetric triage, or urgent care ("outpatient"), and hospital readmissions, may indicate medical complications and signal unmet health needs. Methods: We estimated the incidence of PACU and examined patterns by sociodemographic factors, pregnancy and birth characteristics, time since discharge from the birth hospitalization, and medical indications. We constructed a retrospective cohort of people aged ≥18 years who delivered ≥1 liveborn infant >20 weeks of gestation from July 1, 2021, to December 31, 2022, using electronic health record data from a quaternary maternity hospital in the Southeastern United States PACU data throughout the health care system were collected through March 31, 2023. We excluded people with a hospital stay >6 days (n = 29). Results: In this cohort of 6,041 birthing people, 11.3% had ≥1 outpatient encounters(range 0-6) and 3.2% had ≥1 hospital readmissions (range 0-4) within 12 weeks of discharge from the birth hospitalization. Median time to first outpatient PACU was 10 days post-discharge and 6 days for first hospital readmission. Among encounters for the top five medical indications, time to first postpartum acute care encounter varied by medical indication (log-rank test of equality over strata Chi-square = 69.93, degrees of freedom = 4, p < 0.0001). Complications specified during the puerperium (n = 234) and hypertension and hypertensive-related conditions complicating the puerperium (n = 87) were the two most frequent indications. Conclusion: These findings can inform efforts to direct health resources to improve postpartum health care and health outcomes.

Language and parental satisfaction during inpatient stay: A pilot survey study in a quaternary pediatric hospital.

Considering the significant volume of non-English speakers seeking medical care in the United States and the challenges they may encounter within the hospital environment, it is necessary to assess the satisfaction of non-English-speaking families during their hospital stays and to determine potential areas of improvement in order to optimize care. We aimed to evaluate and describe the satisfaction of Arabic-, Spanish-, and English-speaking families at a quaternary pediatric hospital. From the measures assessed, we sought to identify perceived strengths and weaknesses of the inpatient experience for families who spoke different languages. In doing so, we aimed to identify ways to improve the hospital experience for patients and their families. We created a 23-item satisfaction questionnaire that was vetted by the hospital's Global Services Department, professionally translated into Arabic and Spanish, and tested by native speakers. The survey contained questions pertaining to parent/guardian demographics, their experience with the hospital environment, and their care team or services. Using the questionnaire, we surveyed Arabic-, Spanish-, and English-speaking parents/guardians of post-procedural patients under 18 years of age in intensive care units (ICUs) and on inpatient floors. A total of 162 surveys were collected with roughly equal distribution across the three language groups (52 Arabic, 53 Spanish, 57 English). We found no statistically significant difference in satisfaction scores across the three language groups, nor across self-reported English-proficient and non-English-proficient Arabic and Spanish respondents. In addition, there was no statistically significant difference in satisfaction between parents/guardians in ICUs and those on inpatient floors. This pilot survey suggests that inclusivity and availability of interpretation resources play a role in successfully creating an environment where both English and non-English speakers are satisfied. Further development and validation of the survey instrument should be performed, along with testing at other institutions.

Influence of Inflammatory State on the Need to Customize Parenteral Nutrition in Adolescents

Background/Objectives: Parenteral nutrition (PN) can be standardized or customized according to a patient’s individual needs, including clinical, metabolic, nutritional, and inflammatory conditions. The influence of inflammation on the indication of standard or customized PN for adolescents hospitalized in a quaternary hospital in the southeastern of Brazil was evaluated. Methods: A historical cohort study of 61 adolescents admitted to the hospital was conducted. Nutritional, clinical, and biochemical data from the first 7 days of PN use were analyzed. Elevated serum mineral and triglyceride levels, as well as renal or liver failure (grade III or IV), were considered unequivocal reasons for PN customization, while restoring energy-protein adequacy and low serum mineral levels were considered questionable reasons. Inflammatory status was analyzed during the study period. Results: A total of 128 PN solutions were prescribed, comprising 55 standardized and 73 customized. Overall, 40/61 patients required customized PN. The main reason for customization was to restore energy-protein adequacy (n = 48), while 24.7% (n = 18) of individualizations were for unequivocal reasons. Restoring energy-protein adequacy in the first 48 h was shown to have contributed to high transthyretin, which reduced the need for additional customized PN (r = −0.544; p = 0.044). A positive correlation was found between the total number of PN readjustments and C-Reactive Protein levels (r = 0.509; p = 0.044). Conclusions: Conditions such as malnutrition or an inflammatory state in adolescents presenting metabolic changes are indications for the use of customized PN.

Diagnostic accuracy of ureteric jet angle and location in children with vesicoureteric reflux: A retrospective study

AbstractBackgroundVesicoureteral reflux (VUR) is a common urological abnormality in children that can lead to urinary tract infections and renal scarring. Micturating cystourethrogram (MCU) is the gold standard for diagnosis but is invasive and involves radiation exposure. This study investigates the diagnostic accuracy of ureteric jet angle (UJA) and midline to ureteric orifice distance (MOD) measurements using colour Doppler ultrasonography as a non‐invasive alternative.ObjectivesTo determine the association between UJA and MOD with the presence and severity of VUR in children referred for MCU.MethodsThis retrospective diagnostic accuracy study in an Australian quaternary paediatric hospital included 42 children (68 renal units) referred for MCU to investigate suspected VUR. Colour Doppler ultrasonography was used identify the ureteric jets, permitting measurement of UJA and MOD, which were compared to MCU results (reference standard). Analysis included ROC curves, Mann–Whitney and Kruskal–Wallis tests.ResultsVUR was present in 25 of 68 units (36.8%). Thirty‐two males and 10 females included; mean age 10 months 18 days (range: 26 days to 8 years). Median UJA for VUR units 67.0° (IQR 46.0°) versus non‐VUR 51.0° (IQR 26.0°), p = 0.002. Median MOD for VUR units 8.9 mm (IQR 7.2 mm) versus non‐VUR 5.8 mm (IQR 4.2 mm), p = 0.006.Diagnostic AccuracyUJA: AUC 0.728 (95% CI: 0.590–0.866), optimal cut‐off 56.5°. MOD: AUC 0.701 (95% CI: 0.568–0.835), optimal cut‐off 6.7 mm.DiscussionUJA and MOD measurements show potential as non‐invasive indicators of VUR presence. However, they did not reliably differentiate between individual grades of VUR severity.RegistrationNot applicable.

Prevalence of depression and anxiety in women with polycystic ovary syndrome (PCOS) and associated factors in a quaternary hospital in Thailand: a cross-sectional study

BackgroundPolycystic ovary syndrome (PCOS) is a common gynaecological problem for women of reproductive age. Depression and anxiety are common conditions that occur in women with PCOS and have an impact on mental well-being. However, there is a lack of data on their prevalence and its associated factors in the Thai population. This cross-sectional study aimed to evaluate the prevalence of depression and anxiety among women with PCOS and identify the factors associated with depression and anxiety in women with PCOS as well as their impact on mental well-being in Thailand.MethodsA total of 260 women aged 15 to 40 years diagnosed with PCOS based on the Rotterdam criteria were included in the study. Physical examinations were conducted, and participants completed Hospital Anxiety and Depression Scale (HADS) and Thai version WHO-Five Well-Being Index (WHO-5 Thai) questionnaires to assess depression, anxiety, and mental well-being, respectively. The prevalence and prevalence rations (PR) with 95% confidence interval (CI) for depression and anxiety were analysed using modified Poisson regression analyses with robust variance estimators.ResultsThe prevalence of depression, anxiety, and poor mental well-being among women with PCOS was found to be 3.85%, 11.92%, and 16.92%, respectively. Abdominal obesity (PR 24.25, 95% CI: 2.75–219.50; p = 0.004), poor mental well-being (PR 16.68, 95% CI: 4.02–69.18; p = < 0.001), and snoring (PR 10.26, 95% CI: 2.06–51.14; p = 0.005) were identified as factors associated with depression in women with PCOS. Having children (PR 6.22, 95% CI: 2.90-13.35; p = < 0.001), alcohol drinking (PR 3.41, 95% CI: 1.52–7.65; p = 0.003), poor mental well-being (PR 2.32, 95% CI: 1.14–4.74; p = 0.021), and hirsutism (PR 2.23, 95% CI: 1.18–4.22; p = 0.014) were found to be relative factors for anxiety in women with PCOS.ConclusionWomen with PCOS is associated with high prevalences of depression and anxiety. Poor mental well-being was identified as key factors associated with both depression and anxiety in women with PCOS. Based on these findings, the present study suggests that screening for depression and anxiety should be conducted for all women with PCOS, especially those who present with poor mental well-being.

Modification of McGill Oximetry Score in Improving the Diagnostic Capability of Paediatric OSA.

This study aimed to devise a modified oximetry scoring system and calculate its diagnostic accuracy in detecting paediatric obstructive sleep apnoea syndrome (OSAS). This prospective diagnostic accuracy study was divided into two phases. The study was conducted at a quaternary teaching hospital. Polysomnograms performed from 1 April 2014 to 31 December 2021 were included. In Phase 1, the parameters of 95 oximetry trend graphs were evaluated, and a modified scoring system was constructed. In Phase 2, the modified scoring system was employed in 272 oximetry trend graphs, and its diagnostic accuracy was determined. A logistic regression model was used to assess the ability of each scoring system to predict paediatric OSAS. A total of 367 patients were recruited. In Phase 1, a four-tier severity classification system was constructed. In Phase 2, its diagnostic accuracy was found to be 53.3% sensitive, 97% specific, with positive predictive value of 98.5% and negative predictive value of 34.6%. The lowest detectable apnoea-hypopnoea index (AHI) was 4.5. The inter-rater reliability calculated was 80%. Logistic regression was applied to assess associations of the modified McGill score (MMS) or McGill oximetry score (MOS) with OSAS. The area under the receiver operating characteristic curve was higher for the MMS than for MOS (0.78 [95% CI 0.73-0.84] vs. 0.59 [95% CI 0.51-0.66]). This study demonstrated that our modified scoring system had increased sensitivity at detecting OSAS at a much lower AHI and showed a much greater ability to predict paediatric OSAS.

Comparing PCSK9 inhibitor prescription rates within high-risk populations: diabetes mellitus, multi-territory vascular disease, multivessel and recurrent coronary artery disease

Abstract Background Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are subsidised in Australia for treatment of hypercholesterolemia in particularly high-risk patients with atherosclerotic cardiovascular disease (ASCVD). These high-risk groups are defined as: diabetes mellitus (with age≥60, Aboriginal or Torres Strait Islander origin or microalbuminuria), recurrent ASCVD (≥2 events within 5 years), multivessel coronary disease (≥50% stenosis in ≥2 large vessels) and multi-territory vascular disease (concurrent cerebrovascular or peripheral vascular disease). Methods A retrospective observational analysis was conducted on high-risk patients with LDL&amp;gt;2.6 admitted to a quaternary hospital with ASCVD between 2020-2022. Australian Pharmaceutical Benefits Scheme (PBS) criteria was applied to assess and compare PCSK9 inhibitor eligibility and prescription rates within high-risk populations. Results In total, 477 ASCVD patients with LDL&amp;gt;2.6 were included. This was further categorised into: multivessel coronary disease (n=239, 50.1%), diabetes mellitus (n=60, 12.6%), recurrent ASCVD (n=55, 11.5%) and multi-territory vascular disease (n=32, 6.7%), p&amp;lt;0.001. When 2020 PBS criteria was applied, the number of eligible patients were 16/239 (6.7%), 5/60 (8.3%), 13/55 (23.6%) and 4/32 (12.5%) respectively, p=0.002. Of PBS eligible patients, the number prescribed PCSK9 inhibitors were: 7/16 (43.8%) for multi-vessel coronary disease, 1/5 (20%) for diabetes mellitus, 4/13 (30.8%) for recurrent ASCVD and 1/4 (25%) for multi-territory vascular disease patients (p=0.73). Conclusion Although there was a significantly higher prevalence and proportion of eligible multivessel coronary disease patients, prescribing rates for PCSK9 inhibitor therapy remain low amongst all high-risk eligible groups including diabetes mellitus, multi-territory vascular disease, multivessel and recurrent coronary artery disease.

Mindfulness Exercises Reduce Acute Physiologic Stress Among Female Clinicians.

Approximately 50% of clinicians experience excessive emotional, physical, and mental stress, with repercussions across the entire medical system. Mindfulness exercises may mitigate this excessive stress. Heart rate variability (HRV) is an objective stress measure that can quantify which mindfulness exercises provide the greatest stress reduction. To define the impact of specific mindfulness exercises on HRV, a surrogate for physiologic stress, and the relationship between physiologic (HRV) and subjective stress measured by the State-Trait Anxiety Inventory during a one-day mindfulness workshop. This was a prospective observational pilot study performed at a quaternary children's hospital with diverse subspecialists of pediatric nurses, nurse practitioners, and physicians. Our primary outcome measure was change in HRV from baseline during three mindfulness exercises. The grounding, deep breathing, and body scan exercises all produced statistically significant changes in HRV among our 13 female participants. The body scan exercise produced statistically significant changes in all studied HRV parameters compared with baseline. We observed significant increases in Root Mean Square of Successive Differences between normal heartbeats (p = 0.026), high frequency (p ≤ 0.001), and the parasympathetic nervous system index (p ≤ 0.001) reflecting increased parasympathetic tone (e.g., relaxation), whereas sd 2/sd 1 ratio (p ≤ 0.001) and the stress index (p = 0.004) were decreased reflecting sympathetic withdrawal (e.g., decreased stress). Subjective stress decreased after 1-day mindfulness training (44.6 to 27.2) (p < 0.001). Individuals with the largest decrease in subjective stress also had the most improvement in HRV during the body scan exercise. Clinician stress levels (HRV) improved after participating in grounding, deep breathing, and body scan meditations, which may highlight their importance as stress reduction tools for clinicians. Monitoring of HRV during mindfulness exercises may provide deeper understanding of which specific exercises produce the greatest physiologic stress reduction for individual participants and the trend of these changes over time.

Exploring Collaboration and Social Dynamics in the Paediatric Morbidity and Mortality Meeting, A Qualitative Case Study.

To explore collaboration and social dynamics within paediatric Morbidity and Mortality meetings. Qualitative Exploratory Case Study Methodology incorporating semi-structured interviews and qualitative observations. Data were collected in a large quaternary paediatric hospital in Melbourne, Australia. Semi-structured interviews with meeting attendees were conducted after observing and documenting meeting conduct. Reflexive thematic analysis was used to interpret data and generate a thematic map of findings. Forty-four interviews and 32 meeting observations were conducted between July 2019 and January 2020. Participants valued collaboration between attendees in Morbidity and Mortality meetings, however there were barriers to this. They included differing views about roles and negative impacts of hierarchies and authority. Senior doctors dominated discussion, and participants described this occasionally signalling reverence and respect, but sometimes signified intimidation and feeling unsure about how to contribute. Because of this complexity, successfully achieving positive social dynamics in a meeting required active promotion and management. Morbidity and Mortality meetings mirror the complexity and richness of the clinical environment. Descriptions of how meeting conduct can shape positive workplace culture and address hierarchical obstructions to safe clinical care highlight their far-reaching potential. Effective collaboration is an intrinsic part of realising this value. This paper addresses a paucity in the literature in understanding how social dynamics and collaboration in Morbidity and Mortality meetings are interpreted and experienced. These findings illuminate challenges and obstacles to achieving a productive and equitable social dynamic in meetings. They also illustrate positive discrimination strategies that may improve participation and widespread engagement of nurses, junior doctors, and allied health professionals. Importantly, fostering constructive social dynamics in the Morbidity and Mortality meeting could positively impact patient safety culture and therefore patient care. No patient or public contribution.

Increased physiologic dead space fraction is associated with mortality after comprehensive stage 2 operation.

Our objective was to assess the predictive value of physiologic dead space fraction for mortality in patients undergoing the comprehensive stage 2 operation. This was a single-centre retrospective observational study conducted at a quaternary free-standing children's hospital specialising in hybrid palliation of single ventricle cardiac disease. 180 patients underwent the comprehensive stage 2 operation. 76 patients (42%) underwent early extubation, 59 (33%) standard extubation, and 45 (25%) delayed extubation. We measured time to extubation, post-operative outcomes, length of stay and utilised Fine gray models, Youden's J statistic, cumulative incidence function, and logistic regression to analyse outcomes. Delayed extubation group suffered significantly higher rates of mortality (31.1% vs. 6.8%), cardiac arrest (40.0% vs. 10.2%), stroke (37.8% vs. 11.9%), and need for catheter (28.9% vs. 5.1%) and surgical intervention (24.4% vs. 8.5%) (P < 0.001). Physiologic dead space fraction was significantly higher in the delayed extubation group and in non-survivors with a value of 0.3, which was found to be the discriminatory point by Youden's J statistic. For a 0.1 unit increase in physiologic dead space fraction on post-operative day 1, the odds of a patient expiring increase by a factor of 2.26 (95% CI 1.41-3.97, p < 0.001) and by a factor of 3.79 (95% CI 1.65-11.7, p 0.01) on post-operative day 3. Delayed extubation impacts morbidity and mortality in patients undergoing the comprehensive stage 2 operation. Increased physiologic dead space fraction in the first 60 hours after arrival to the ICU is associated with higher mortality.

Benefits of emergency department routine blood test performance on patients whose allocated triage category is not time critical: a retrospective study

IntroductionEmergency department clinicians, and particularly nurses in triage, frequently perform routine blood tests on patients whose allocated triage category is not time critical (triage categories 3, 4 and 5 of the Australasian Triage Scale). Some observers have questioned the utility of routine blood testing in these acute healthcare settings given the cost and workload implications.MethodsA quantitative method using retrospective observational design was utilised guided by STROBE checklist. Electronic medical records of patient data collected at a quaternary Australian metropolitan hospital emergency department were reviewed.Results and discussionA total of 74,878 adult patients attended the emergency department between 1st January and 31st December 2021 and a sample of 383 were randomly allocated for this study. Of the 383 patients included, 51% were female, age ranges were 18–99 years (mean 51.6). The majority were Australasian Triage scale (ATS) triage category 3 (55%) and 62% had blood tests performed. Blood test performance was found to be associated with advancing age (p < 0.001) but not with department occupancy as determined by the national emergency department overcrowding scale (p = 0.230).ConclusionBlood testing in the emergency department in triaged non-time critical patients was found to be frequent thereby affecting nurses’ already stretched time resource. Older patients were found to be more likely to have a blood test. There is a positive correlation between blood test performance and length of stay in the emergency department.

Elevating care: assessing the impact of telemonitoring on diabetes management at a cutting-edge quaternary hospital.

To assess whether post-discharge telemonitoring reduces hospital readmission in patients participating in the diabetes care program. This retrospective cohort study was conducted from June 2021 to December 2022 and included patients who were enrolled in the Diabetes Program under a hyperglycemia treatment protocol and eligible for post-discharge telemonitoring. The variables included age, sex, diagnosis, hospital stay, LACE Score, and readmission rate. Among 165 patients who underwent telemonitoring, significant differences emerged in hospital readmission rates between those with and without telemonitoring (p=0.015), with a 15.4% lower readmission rate in the telemonitoring group (95%CI= 3.0-27.9%). Subgroup analyses revealed higher readmission rates in men without telemonitoring (15.2% difference; 95%CI= 0.4-30.0%; p=0.045), and in age groups ≤60 and ≥75 years without telemonitoring (24.2% difference; 95%CI= 4.5-43.9%; p=0.016 for ≤60 years; 37.1% difference; 95%CI= 9.9% to 64.2%; p=0.007 for ≥75 years). Additionally, patients with prolonged hospital stays (>7 days) without telemonitoring had higher readmission rates (19.5% difference; 95%CI= 4.5%-34.5%; p=0.011). This study suggests that post-discharge telemonitoring can effectively lower hospital readmission rates in diabetes management programs, potentially offering improved health outcomes, cost savings, and enhanced healthcare delivery to patients.

The Impact of Clinical Pharmacist-Driven Weekend Antimicrobial Stewardship Coverage at a Quaternary Hospital.

Extending a consistent pharmacy antimicrobial stewardship weekend service was a newly implemented initiative. We sought to evaluate the impact of incorporating an Infectious Diseases (ID)-trained clinical pharmacist into an antimicrobial stewardship program (AMS) during weekends. The number of documented interventions was 451 on 362 patients compared to 115 interventions on 108 patients during the pre-implementation period (p = 0.04), with interventions primarily targeting Watch antibiotics, as classified by the WHO AWaRe classification. A reduction in the LOS was observed, with a median of 16 days (8-34) during the post-implementation period compared to 27.5 days (10-56) during the pre-implementation period (p = 0.001). The median DOT increased during the post-implementation period to 8 (6-11), versus the increase to 7 (4-11) during the pre-implementation period (p ≤ 0.001). Finally, there was no significant difference observed in healthcare-associated CDI and infection-related readmission. This is a retrospective single-center, pre-post quasi-experimental study. Data including the documented pharmacist interventions were collected from the electronic medical record (EMR), the pre-implementation phase was in 2020, and post-implementation was in 2021. The primary outcome was to identify the number of AMS interventions through prospective audit and feedback review analysis. Secondary outcomes included antibiotic days of therapy (DOT), length of hospital stay (LOS), healthcare-associated Clostridioides difficile infection (CDI), and infection-related readmission. The pharmacist-driven weekend AMS is an opportunity for pharmacists to intervene and optimize patients' care plans. This initiative demonstrated significant increased AMS-related interventions, promoted judicious antimicrobial use, and contributed to a reduced length of hospital stay. Our findings need to be replicated in a larger prospective study.

Eighteen-year trends in the rates of intra-operative cardiac arrest and associated mortality at a public university hospital in Brazil.

Intra-operative cardiac arrest is a rare but life-threatening event. Over the past two decades, various initiatives have improved the care of patients undergoing surgery at our quaternary teaching hospital in Brazil. We aimed to evaluate the epidemiology of intra-operative cardiac arrest and associated 30-day mortality over an 18-year period. A secondary aim was to identify associated risk factors. We conducted a retrospective observational study using data collected from 1 January 2005 to 31 December 2022. Factors associated with cardiac arrest and mortality were identified using multivariable logistic regression analysis. Among the 154,178 cases, the overall rates of intra-operative cardiac arrest (n = 297) and associated 30-day mortality (n = 248) were 19.3 (95%CI (16.6-21.9)) and 16.1 (95% CI 13.9-18.3) per 10,000 anaesthetics, respectively. These decreased over time (2005-2010 vs. 2017-2022) from 26.3 (95%CI 21.0-31.6) to 15.4 (95%CI 12.0-18.7) per 10,000 anaesthetics, and from 23.4 (95%CI 18.8-28.1) to 13.7 (95%CI 10.8-16.7) per 10,000 anaesthetics, respectively. Factors associated with intra-operative cardiac arrest included children aged < 1 year (adjusted OR (95%CI) 3.51 (1.87-6.57)); ASA physical status 3-5 (adjusted OR (95%CI) 13.85 (8.86-21.65)); emergency surgery (adjusted OR (95%CI) 10.06 (7.85-12.89)); general anaesthesia (adjusted OR (95%CI) 8.79 (4.60-19.64)); surgical procedure involving multiple specialities (adjusted OR (95%CI) 9.13 (4.24-19.64)); cardiac surgery (adjusted OR (95%CI) 7.69 (5.05-11.71)); vascular surgery (adjusted OR (95%CI) 6.21 (4.05-9.51)); and gastrointestinal surgery (adjusted OR (95%CI) 2.98 (1.91-4.65)). We have shown an important reduction in intra-operative cardiac arrest and associated 30-day mortality over an 18-year period. Identification of relative risk factors associated with intra-operative cardiac arrest can be used to improve the safety and quality of patient care, especially in a resource-limited setting.

Risk factors for central line-associated bloodstream infection in the pediatric intensive care setting despite standard prevention measures.

Identify risk factors for central line-associated bloodstream infections (CLABSI) in pediatric intensive care settings in an era with high focus on prevention measures. Matched, case-control study. Quaternary children's hospital. Cases had a CLABSI during an intensive care unit (ICU) stay between January 1, 2015 and December 31, 2020. Controls were matched 4:1 by ICU and admission date and did not develop a CLABSI. Multivariable, mixed-effects logistic regression. 129 cases were matched to 516 controls. Central venous catheter (CVC) maintenance bundle compliance was >70%. Independent CLABSI risk factors included administration of continuous non-opioid sedative (adjusted odds ratio (aOR) 2.96, 95% CI [1.16, 7.52], P = 0.023), number of days with one or more CVC in place (aOR 1.42 per 10 days [1.16, 1.74], P = 0.001), and the combination of a chronic CVC with administration of parenteral nutrition (aOR 4.82 [1.38, 16.9], P = 0.014). Variables independently associated with lower odds of CLABSI included CVC location in an upper extremity (aOR 0.16 [0.05, 0.55], P = 0.004); non-tunneled CVC (aOR 0.17 [0.04, 0.63], P = 0.008); presence of an endotracheal tube (aOR 0.21 [0.08, 0.6], P = 0.004), Foley catheter (aOR 0.3 [0.13, 0.68], P = 0.004); transport to radiology (aOR 0.31 [0.1, 0.94], P = 0.039); continuous neuromuscular blockade (aOR 0.29 [0.1, 0.86], P = 0.025); and administration of histamine H2 blocking medications (aOR 0.17 [0.06, 0.48], P = 0.001). Pediatric intensive care patients with chronic CVCs receiving parenteral nutrition, those on non-opioid sedative infusions, and those with more central line days are at increased risk for CLABSI despite current prevention measures.

Outcomes of tunnelled cuffed centrally inserted central catheter removal: A retrospective cohort study.

Most children with cancer will require a central venous access device (CVAD) to administer cancer treatment. A commonly used CVAD is a tunnelled cuffed centrally inserted central catheter (TC-CICC). There is little information available to guide best practice when removing this type of CVAD. At our institution, TC-CICCs are removed by using either the traction or dissection methods. This study will describe the outcomes associated with each technique. A retrospective cohort study was undertaken at a quaternary children's hospital in Melbourne, Australia. Data related to characteristics of TC-CICC removal success, post-removal complications and an economic evaluation were carried out. There were 149 patients who underwent traction removal and 100 who had their TC-CICC removed using the dissection technique. In the traction group, 136/149 (91%) patients had their device successfully removed on the first attempt, whereas 99/100 (99%) were removed on the first attempt with dissection. Of the 136 successful traction removals, cuff status was documented in 72 cases. The cuff remained in situ in 46/72 (64%) cases, and six of 72 (8%) patients experienced a complication. There were no documented cases of cuff retention in the dissection group. In the 2019-2020 financial year, the estimated average cost of traction removal was A$387, whereas the estimated average cost of day case surgery was A$2560. This study has highlighted that the traction technique is a safe, efficient and cost-effective approach to TC-CICC removal. Further research is required to understand the patient and family experience of TC-CICC removal.

Parenteral nutrition customization in pediatrics: A descriptive cohort study.

The main objective of this study was to analyze the reasons for customizing parenteral nutrition (PN) in pediatric patients admitted to a quaternary hospital. We performed a descriptive cohort study on 264 hospitalized children receiving PN. Anthropometric, biochemical, and hospitalization data were collected from patient records. Unequivocal reasons for customizing PN were defined as situations precluding prescription of a standard adult/teenager PN and included renal and/or liver failure, energy-protein adequacy, and elevated mineral and triglyceride levels. A total of 264 patients, with a median age of 2.2 years (IQR: 0.3-9.0 years), comprising intensive care (n = 216; 81.8%) and malnourished (n = 91; 36.1%) patients, were evaluated. In the first 48 h, 87.9% (n = 232) of the sample required customized PN for energy-protein adequacy (210 of 232), maintained over subsequent days in most cases. Among patients requiring second individualization, mineral disturbance was the main reason observed, especially within the first 4 days of PN use (n = 21; 60%). Unequivocal reasons for customizing PN occurred in 97.4% (n = 226) of cases in the first 48 h; 96.2% (n = 177) of cases on the fourth day; and 90.1% (n = 92) of cases on the seventh day of PN use. An inverse correlation was found between weight/age z score and number of second individualizations (r = -0.222; P = 0.002). Customized PN proved essential, especially for younger, malnourished, and intensive care patients. Investment in training a Nutritional Multidisciplinary Therapy Team and acquiring a specific electronic system for prescribing PN is suggested.

Importance of risk adjusting central line-associated bloodstream infection rates in children.

Central line-associated bloodstream infection (CLABSI) is one of the most prevalent pediatric healthcare-associated infections and is used to benchmark hospital performance. Pediatric patients have increased in acuity and complexity over time. Existing approaches to risk adjustment do not control for individual patient characteristics, which are strong predictors of CLABSI risk and vary over time. Our objective was to develop a risk adjustment model for CLABSI in hospitalized children and compare observed to expected rates over time. We conducted a prospective cohort study using electronic health record data at a quaternary Children's Hospital. We included hospitalized children with central catheters. Risk factors identified from published literature were considered for inclusion in multivariable modeling based on association with CLABSI risk in bivariable analysis and expert input. We calculated observed and expected (risk model-adjusted) annual CLABSI rates. Among 16,411 patients with 520,209 line days, 633 patients experienced 796 CLABSIs. The final model included age, behavioral health condition, non-English speaking, oncology service, port catheter type, catheter dwell time, lymphatic condition, total parenteral nutrition, and number of organ systems requiring ICU level care. For every organ system receiving ICU level care the odds ratio for CLABSI was 1.24 (95% CI 1.12-1.37). Although not statistically different, observed rates were lower than expected rates for later years. Failure to adjust for patient factors, particularly acuity and complexity of disease, may miss clinically significant differences in CLABSI rates, and may lead to inaccurate interpretation of the impact of quality improvement efforts.

Biomarkers and Diagnostic Thresholds for Congenital Hyperinsulinism.

Congenital Hyperinsulinism (CHI) is associated with inappropriately high levels of C-peptide in the context of hypoglycemia. We aimed to better clarify a diagnostic threshold value of C-peptide for children presenting with CHI. This was a retrospective case-control analysis, examining all hypoglycemia screens, undertaken between 2009 and 2019 at a quaternary paediatrics unit. Plasma C-peptide, insulin, free fatty acid (FFA) and B-hydroxybutyrate (BHOB) concentrations in children diagnosed with CHI were compared with concentrations in children diagnosed with other conditions. All patients requiring hypoglycaemic screens at the quaternary children's hospital were analysed. Median [C-peptide] were statistically significantly different between CHI (147) and non-CHI (72) patients, p < 0.05. The Youden Index indicated that a [C-peptide] value of 291.5 pmol/L would give the greatest optimization of sensitivity (82%) and specificity (99%) for detecting CHI. Median [insulin] differed significantly between the cohorts with a level of 64 pmol/L for CHI patients compared with 0 pmol/L with non-CHI patients (p < 0.01). Median [BOHB] was 0 μmol/L in CHI patients as compared with 2378 μmol/L for non-CHI patients (p < 0.01). Median [FFA] levels were 1910 μmol/L in the non-CHI cohort, compared with 0 in the CHI cohort (p < 0.01). This study suggests that a C-peptide concentration greater than 291.5 pmol/L is diagnostic of CHI in children. C-peptide appears to offer the greatest utility as a biochemical diagnostic test for CHI and could be prioritised for laboratory analysis.