Regional Pediatric Center Research Articles

Abnormal arterial anatomy and an unexpected intracranial haemorrhage

A baby boy was born at term by spontaneous vaginal delivery to non-consanguineous parents following an unremarkable pregnancy. He was admitted to his local neonatal intensive care unit shortly after...

P48 The puppet prescriber or custodian of the NHS purse: are patients really at the centre of what we do?

Abstract Background Biologic therapies have revolutionised the management of patients with rheumatological conditions; with considerable cost to the NHS. The switch of originators to biosimilar products was challenging. We aim to share our experience of adalimumab biosimilar switch and believe this is reflective of the challenges experienced in some other centres. The development of biosimilar aims to challenge the excesses of pharma profits by encouraging competition in the market place. Previous switches to intravenous biosimilar products had been uneventful. We were informed that the trust was implementing switch of biologics to biosimilar and later told biosimilar A was the biosimilar version allocated to us. This was a decision beyond the Trust, with NHS England deciding on the allocation. For our Trust, biosimilar A was allocated for patients weighing 30kg requiring a 40mg dose and biosimilar B allocated for patients weighing less than 30kg requiring a 20mg dose (NB: no 20mg preparation available for biosimilar A). Patients commenced on biosimilar B 20mg preparation can remain on biosimilar B and move on to its 40mg preparation once they weigh 30kg. Biosimilar A, the cheaper of the two preparations, contains preservative, citrate. Both biosimilars are double the volume of the originator biologic. Case a biologic-naïve 16 year-old patient was the first to be treated with the chosen biosimilar A, and, upon self-administrating; the patient clearly expressed a high level of pain. Following the experience with the patient the team felt that this was not an appropriate option. Methods With the feedback from the patient, rheumatology team highlighted the issues and focussed on high quality patient centred care not just focussing on the short term cost saving option but understanding that the patient engagement and compliance is cost saving in the long run. The team enquired with other specialities and regional paediatric rheumatology centres regarding their biosimilar switch. Results Liaising with the High cost pharmacy team, we successfully obtained authorisation to prescribe biosimilar B. We promptly switched the patient to biosimilar B and prescribe this now for all suitable to switch and new patients. So far there have been no negative comments or issues from the switch to the citrate free product. Conclusion It is vital that we provide an evidence based cost saving medication to treat children with long term conditions. However when new medications are being introduced, there needs to be greater consideration for the paediatric population which currently seems lacking. Collaborative working with the high cost pharmacy team, regular communications with other specialities, adult colleagues and involving the national nurse specialists group greatly benefitted us in managing this situation. More studies are required to identify patient factors involved in these scenarios. Conflicts of Interest The authors declare no conflicts of interest.

Antibiotic or silver versus standard ventriculoperitoneal shunts (BASICS): a multicentre, single-blinded, randomised trial and economic evaluation

SummaryBackgroundInsertion of a ventriculoperitoneal shunt for hydrocephalus is one of the commonest neurosurgical procedures worldwide. Infection of the implanted shunt affects up to 15% of these patients, resulting in prolonged hospital treatment, multiple surgeries, and reduced cognition and quality of life. Our aim was to determine the clinical and cost-effectiveness of antibiotic (rifampicin and clindamycin) or silver shunts compared with standard shunts at reducing infection.MethodsIn this parallel, multicentre, single-blind, randomised controlled trial, we included patients with hydrocephalus of any aetiology undergoing insertion of their first ventriculoperitoneal shunt irrespective of age at 21 regional adult and paediatric neurosurgery centres in the UK and Ireland. Patients were randomly assigned (1:1:1 in random permuted blocks of three or six) to receive standard shunts (standard shunt group), antibiotic-impregnated (0·15% clindamycin and 0·054% rifampicin; antibiotic shunt group), or silver-impregnated shunts (silver shunt group) through a randomisation sequence generated by an independent statistician. All patients and investigators who recorded and analysed the data were masked for group assignment, which was only disclosed to the neurosurgical staff at the time of operation. Participants receiving a shunt without evidence of infection at the time of insertion were followed up for at least 6 months and a maximum of 2 years. The primary outcome was time to shunt failure due the infection and was analysed with Fine and Gray survival regression models for competing risk by intention to treat. This trial is registered with ISRCTN 49474281.FindingsBetween June 26, 2013, and Oct 9, 2017, we assessed 3505 patients, of whom 1605 aged up to 91 years were randomly assigned to receive either a standard shunt (n=536), an antibiotic-impregnated shunt (n=538), or a silver shunt (n=531). 1594 had a shunt inserted without evidence of infection at the time of insertion (533 in the standard shunt group, 535 in the antibiotic shunt group, and 526 in the silver shunt group) and were followed up for a median of 22 months (IQR 10–24; 53 withdrew from follow-up). 32 (6%) of 533 evaluable patients in the standard shunt group had a shunt revision for infection, compared with 12 (2%) of 535 evaluable patients in the antibiotic shunt group (cause-specific hazard ratio [csHR] 0·38, 97·5% CI 0·18–0·80, p=0·0038) and 31 (6%) of 526 patients in the silver shunt group (0·99, 0·56–1·74, p=0·96). 135 (25%) patients in the standard shunt group, 127 (23%) in the antibiotic shunt group, and 134 (36%) in the silver shunt group had adverse events, which were not life-threatening and were mostly related to valve or catheter function.InterpretationThe BASICS trial provides evidence to support the adoption of antibiotic shunts in UK patients who are having their first ventriculoperitoneal shunt insertion. This practice will benefit patients of all ages by reducing the risk and harm of shunt infection.FundingUK National Institute for Health Research Health Technology Assessment programme.

Is Treatment Working? Detecting Real Change in the Treatment of Child and Adolescent Depression.

Despite advances in evidence-based treatments for youth depression in recent decades, overall treatment effects are modest at best, with 30% to 50% of youth being nonresponders. Practice parameters consistently recommend systematic assessment and routine monitoring of depressive symptoms, or measurement-based care (MBC), to enhance youth depression treatment. However, the literature offers few guidelines on how to use assessment results to inform care decisions or to detect real and clinically meaningful change. Thus the current study produced reliable change indices (RCIs) per Jacobson and Truax for two commonly used standardized assessments of youth depression (ie, Patient Health Questionnaire-9 items, Modified for Adolescents [PHQ-9A], the Short Moods and Feelings Questionnaire [SMFQ]). The study sample (N= 1,738) consisted of youths 6 to 18 years old seen in a child and adolescent psychiatry clinic of a regional pediatric medical center who completed at least one of the target depression measures. We examined the factor structure and internal reliability for the PHQ-9A, and calculated RCIs for patients with a depression-related diagnosis for both measures. Analyses confirmed a one-factor solution and adequate internal consistency (α= .86) for the PHQ-9A. All measures yielded acceptable test-retest reliabilities (r > 0.75) and RCIs that equate to clinical practice recommendations of using reliable changes scores of 7, 6, and 8 for the PHQ-9A, the SMFQ-Child Report, and the SMFQ-Parent Report, respectively. Psychometric validation of the PHQ-9A and these RCIs are timely and significant contributions to the treatment of youth depression, by facilitating effective use of MBC-a critical evidence-based strategy for improving treatment outcomes.

The benefit of surveillance imaging for paediatric cerebellar pilocytic astrocytoma.

Paediatric cerebellar pilocytic astrocytomas (PA) (WHO grade 1) are amongst the most common of childhood brain tumours and are generally amenable to resection, with surgery alone being curative in the majority of cases. There is, however, a lack of consensus regarding the frequency and duration of post-treatment MRI surveillance for these tumours. This is important, as follow-up imaging is a significant use of resources and often associated with patient and family anxiety. We have assessed the utility of MRI surveillance in the detection of cerebellar PA recurrence at our regional paediatric neurosurgical centre. The tumour register at Alder Hey Children's Hospital was searched to identify all patients diagnosed between 2007 and 2017, with a confirmed histopathological diagnosis of cerebellar PA. Patient demographics, surgical outcome, number of MRI scans and length of follow-up were recorded for each patient. Forty patients met the inclusion criteria. The mean age at diagnosis was 7.8years (range 2 to 17years). Complete surgical resection (CR), confirmed by post-operative MRI, was achieved in 36 of the 40 patients, including all 31 cases from 2009 and later for which intraoperative MRI (iMRI) was utilised. There was one case of recurrence after CR (at 2.2years) out of the 36 cases, whereas all 4 patients with initial partial resections had progressive growth of their tumours and required second surgical interventions. This series confirms the very low likelihood of recurrence for completely resected cerebellar PAs and suggests that in such cases the duration and frequency of surveillance imaging could be limited to a maximum of 2.5 to 3years of follow-up imaging. This report also indicates improved complete resection rates over time, probably associated with technical advances including the routine in-house use of iMRI in 2009.

Presentation and Investigation of Pediatric Bone and Joint Infections in the Pediatric Emergency Department.

The objective of this study was to evaluate the presenting features of bone and joint infections with a view to identify distinguishing trends that will be useful for pediatric emergency departments. We performed a retrospective review of patient records over a 12-year period in the pediatric emergency department of a large regional pediatric teaching center serving a diverse population. There were 88 cases of osteoarticular infections during the study period. Pain, fever, and impaired function were commonly reported, but overall, there was inconsistency in the presenting features. Inflammatory makers were sensitive tools, particularly in combination. When C-reactive protein, total white cell count, and erythrocyte sedimentation rate were all abnormal, 98% of bone and joint infections were identified.Causative organisms were identified in only 38% of cases, mostly from cultures of synovial fluid and bone. Streptococcal organisms were significantly more likely to be isolated in children under 5 years than in children over 5 years (P = <0.014). Staphylococcal organisms were significantly more likely to be isolated in children over 5 years than in children under 5 years (P = <0.001). Identification of virulent organisms such as Panton-Valentine leukocidin Staphylococcus aureus and methicillin-resistant S. aureus in our study should prompt review of diagnostic techniques and antibiotic choices. Overall, children under 5 years were significantly more likely to be diagnosed with septic arthritis than osteomyelitis (P = 0. 006). Children over 12 years were significantly more likely to be diagnosed with osteomyelitis than septic arthritis (P = 0. 019). These trends are useful to consider at presentation and in cases of diagnostic uncertainty.

Adequate working hours and skill earning.

Long working hours have caused many pediatricians to burn out and become depressed, and, as a result, many human errors have occurred, not only in outpatient clinics but also in inpatient wards. This phenomenon has also been observed in the neonatal intensive care unit, obstetrics and gynecology, and in surgical subspecialties. To prevent these human errors, the US Accreditation Council for Graduate Medical Education (ACGME) has set a cap of 80 h/week, and also a mandate on the amount of sleep/personal time for residents (10 h between shifts), as well as the maximum length of shifts (16 h with 30 h maximums), and the number of overnight calls (no more than once every 3 days). The European Union working time directive has also set 48 h as the maximum limit. These restrictions, however, generated criticisms with regard to the resulting lower volume of experience and slower acquirement of higher skills. After two resident deaths by suicide in New York City in 2014 within 1 week of each other, the ACGME called to national leaders and ran symposia on physician wellbeing in November 2015 and 2016. As a result, the American Pediatric Society National Conference ran a session named Peds21 – Pediatricians Leading Change in Physician Health and Wellness, in Chicago, September 2017, to address the relationship between burnout, job satisfaction, quality care and patient safety, and also to teach self-resilience. In the meantime, the Japan Pediatric Society has also strived to reduce pediatrician working hours by concentrating the workforce and inpatient beds into bigger regional pediatric centers, not only to prevent pediatrician exhaustion and suicide, but also to improve teamwork and achieve better patient outcomes. To ensure this, higher volumes of experience and skill earning in adequate working hours are crucial in clinical settings worldwide. The author declares no conflict of interest.

Variability in Imaging Practices and Comparative Cumulative Effective Dose for Neuroblastoma and Nephroblastoma Patients at 6 Pediatric Oncology Centers.

The purpose of this study was to estimate the cumulative effective dose (CED) from diagnosis and posttherapy computed tomographic (CT) scans performed on children treated for neuroblastoma or nephroblastoma (Wilms tumor) and to examine the different imaging practices used in 6 regional pediatric oncology centers between January 2010 and December 2013. We analyzed retrospectively the CT scan acquisition data in children aged 10 years or younger at diagnosis. The use of nonionizing imaging modalities was reported. The CT examinations of 129 children, with a mean age at diagnosis of 36 months, treated for 66 neuroblastomas and 63 nephroblastomas, were analyzed. The mean follow-up period was 28 months (minimum, 8 months, maximum, 41 mo). There were 600 CT scans, with a total of 1039 acquisitions. The mean CED from CT scans was 27 mSv (minimum=18.25, maximum=45). Abdominal CT examinations contributed 85% of the total CED. A median of 4.6 CT scans, 10.3 sonograms, and 0.4 magnetic resonance imaging examinations per child were performed. Our results suggest a reduction in radiation exposure but variability in the imaging modality choice and acquisition protocols. We emphasize the need for consensus and standardization in oncologic pediatric imaging procedures. When feasible, we encourage the substitution of nonionizing examinations for CT.

Inferior vena caval aneurysm - an unusual cause of back pain in a young girl

Introduction Aneurysms are defined as an abnormal dilation of an artery, vein or cardiac chamber. Aneurysms affecting the inferior vena cava (IVC) are rare, with just over 50 cases in the published literature. They are associated with caval thrombosis. We will discuss the aetiology and management of such cases. Case description A 14-year-old girl presented to her local hospital complaining of a two week history of worsening back pain, swelling and discolouration of the legs, and reduced mobility. Imaging suggested a psoas abscess, and drainage was arranged at a regional paediatric centre. Upon review, repeat imaging was sought which indicated an IVC aneurysm rather than a psoas abscess. There was thrombosis within the dilatation extending to the femoral veins which accounted for her symptoms. Results and conclusions The patient was anticoagulated in the first instance. The duration of the symptoms meant it was too late for thrombolysis, and the occluded segment was considered too long for conventional venous stenting. She has been placed in compression hosiery and referred to the national centre for ongoing management. Take-home message Unusual presentations are often caused by rare pathologies. In any patient presenting with bilateral swollen, purple legs; it is imperative to establish if there is any venous occlusion. This was also an important lesson in being wary of draining supposed psoas abscesses in young patients.

Perfusion Index and Pulse Oximetry Screening for Congenital Heart Defects

To evaluate the efficacy of combined pulse oximetry (POX) and perfusion index (PI) neonatal screening for severe congenital heart defects (sCHD) and assess different impacts of screening in tertiary and nontertiary hospitals. A multicenter, prospective study in 10 tertiary and 6 nontertiary maternity hospitals. A total of 42 169 asymptomatic newborns from among 50 244 neonates were screened; exclusion criteria were antenatal sCHD diagnosis, postnatal clinically suspected sCHD, and neonatal intensive care unit admission. Eligible infants underwent pre- and postductal POX and PI screening after routine discharge examination. Targeted sCHD were anatomically defined. Positivity was defined as postductal oxygen saturation (SpO2) ≤95%, prepostductal SpO2 gradient >3%, or PI <0.90. Confirmed positive cases underwent echocardiography for definitive diagnosis. Missed cases were identified by consulting clinical registries at 6 regional pediatric heart centers. Main outcomes were incidence of unexpected sCHD; proportion of undetected sCHD after discharge in tertiary and nontertiary hospitals; and specificity, sensitivity, positive predictive value, and negative predictive value of combined screening. One hundred forty-two sCHD were detected prenatally. Prevalence of unexpected sCHD was 1 in 1115 live births, similar in tertiary and nontertiary hospitals. Screening identified 3 sCHD (low SpO2, 2; coarctation for low PI, 1). Four cases were missed. In tertiary hospitals, 95% of unsuspected sCHDs were identified clinically, whereas only 28% in nontertiary units; in nontertiary units PI-POX screening increased the detection rate to 71%. PI-POX predischarge screening provided benefits in nontertiary units, where clinical recognition rate was low. PI can help identify coarctation cases missed by POX but requires further evaluation in populations with higher rates of missed cases.

Pathways to reduce diabetic ketoacidosis with new onset type 1 diabetes: Evidence from a regional pediatric diabetes center: Auckland, New Zealand, 2010 to 2014.

There has been little change in the incidence of diabetic ketoacidosis (DKA) in newly diagnosed type 1 diabetes mellitus (T1DM) in children and adolescents in most developed countries. To assess potentially modifiable antecedents of DKA in children <15 years of age with new onset T1DM. Retrospective review of prospectively collected data from a complete regional cohort of children with T1DM in Auckland (New Zealand) from 2010 to 2014. DKA and severity were defined according to the ISPAD 2014 guidelines. A total of 263 children presented with new onset T1DM during the 5-year study period at 9.0 years of age (range 1.0-14.7), of whom 61% were NZ-European, 14% Maori, 13% Pacifica, and 11% other. A total of 71 patients (27%) were in DKA, including 31 mild, 20 moderate, and 20 severe DKA. DKA was associated with no family history of T1DM, higher glycated hemoglobin (HbA1c) values at presentation, self-presenting to secondary care, health care professional contacts in the 4 weeks before final presentation, and greater deprivation. Although a delay in referral from primary care for laboratory testing was common (81/216), only delay for more than 48 hours was associated with increased risk of DKA (11/22 > 48 h vs 12/59 referred at <48 h, P = .013). These data suggest that in addition to lack of family awareness potentially modifiable risk factors for new onset DKA include prolonged delay for laboratory testing and a low index of medical suspicion for T1DM leading to delayed diagnosis.

Ethnic Differences in Incidence and Outcomes of Childhood Nephrotic Syndrome.

Ethnic differences in outcomes among children with nephrotic syndrome are unknown. We conducted a longitudinal study at a single regional pediatric center comparing ethnic differences in incidence from 2001 to 2011 census data and longitudinal outcomes, including relapse rates, time to first relapse, frequently relapsing disease, and use of cyclophosphamide. Among 711 children, 24% were European, 33% were South Asian, 10% were East/Southeast Asian, and 33% were of other origins. Over 10 years, the overall incidence increased from 1.99/100,000 to 4.71/100,000 among children ages 1-18 years old. In 2011, South Asians had a higher incidence rate ratio of 6.61 (95% confidence interval, 3.16 to 15.1) compared with Europeans. East/Southeast Asians had a similar incidence rate ratio (0.76; 95% confidence interval, 0.13 to 2.94) to Europeans. We determined outcomes in 455 children from the three largest ethnic groups with steroid-sensitive disease over a median of 4 years. South Asian and East/Southeast Asian children had significantly lower odds of frequently relapsing disease at 12 months (South Asian: adjusted odds ratio; 0.55; 95% confidence interval, 0.39 to 0.77; East/Southeast Asian: adjusted odds ratio; 0.42; 95% confidence interval, 0.34 to 0.51), fewer subsequent relapses (South Asian: adjusted odds ratio; 0.64; 95% confidence interval, 0.50 to 0.81; East/Southeast Asian: adjusted odds ratio; 0.47; 95% confidence interval, 0.24 to 0.91), lower risk of a first relapse (South Asian: adjusted hazard ratio, 0.74; 95% confidence interval, 0.67 to 0.83; East/Southeast Asian: adjusted hazard ratio, 0.65; 95% CI, 0.63 to 0.68), and lower use of cyclophosphamide (South Asian: adjusted hazard ratio, 0.82; 95% confidence interval, 0.53 to 1.28; East/Southeast Asian: adjusted hazard ratio, 0.54; 95% confidence interval, 0.41 to 0.71) compared with European children. Despite the higher incidence among South Asians, South and East/Southeast Asian children have significantly less complicated clinical outcomes compared with Europeans.

Lung ultrasound: a novel technique for detecting fluid overload in children on dialysis.

Optimizing the target weight of infants and children on dialysis remains an important clinical challenge. The use of ultrasound to detect fluid overload in adult patients on dialysis is receiving growing attention. We hypothesized that fluid overload can be quantified in infants and children receiving dialysis using lung ultrasound. In this prospective observational study, infants and children receiving dialysis for end-stage renal disease (ESRD) or acute kidney injury (AKI) in a regional paediatric nephrology centre were eligible. Lung ultrasound examinations were performed during in-centre dialysis, on home visits or in an outpatient clinic. Fluid overload was assessed by quantifying B-lines on ultrasound and compared with proportional (%) increase in patient weight from the target weight. A total of 142 ultrasound assessments were performed in 23 children. In children with AKI, median B-line score reduced from 5 (range 0-22) at presentation to 1.5 (0-4) at recovery (P = 0.04) with concurrent improvement in fluid overload judged by weight from 7.2 (-1.9 to 15.2)% to 0%. A linear correlation between lung ultrasound B-line score and fluid overload judged by weight was observed in children with AKI (r = 0.83) and ESRD (r = 0.61). Inter-observer variability was acceptable. Lung ultrasound is a practical and sensitive method of quantifying subclinical fluid overload in infants and children on dialysis. Interventional studies to determine the benefits of using lung ultrasound to optimize the target weight for children with ESRD are merited.

The impact and efficacy of routine pulse oximetry screening for CHD in a local hospital.

The objective of this study was to evaluate the impact and efficacy of pulse oximetry screening for CHD in a level-two neonatal unit without on-site access to paediatric echocardiography. All neonatal unit admissions between 1 September, 2011 and 31 August, 2013 were reviewed to determine the outcomes of newborns identified by pulse oximetry screening. Record linkage with the National Congenital Heart Disease Audit allowed follow-up of newborns with a negative screening result. There were 11,233 live births during the study period, with 973 neonatal unit admissions unrelated to pulse oximetry screening. From the remaining screening population of 10,260 newborns, 23 were admitted on the basis of a screen-positive result; three of the 23 patients went on to have urgent echocardiograms, and two were found to have critical CHD. In the 21 newborns without critical CHD, an alternative diagnosis was made in 16 cases. Record linkage with the National Congenital Heart Disease Audit indicated that no newborns born in the hospital during the study period received surgery for critical CHD following negative screening. The estimated sensitivity of screening was 100% (95% confidence interval 15.81-100%) and specificity was 99.80% (95% confidence interval 99.69-99.87%), with a false-positive rate of 0.20% (95% confidence interval 0.13-0.31%). The introduction of pulse oximetry screening to a hospital where paediatric echocardiography services are not available is practical, results in very few referrals to the regional paediatric cardiology centre, and detects cases of CHD that would otherwise go undiagnosed. Record linkage with a national CHD database provides a straightforward method for tracking cases of CHD that may have been missed by screening.

Heterotaxy and intestinal rotation anomalies: 20 years experience at a UK regional paediatric surgery centre.

The association of heterotaxy with intestinal rotation anomalies is well described. However debate exists with regard optimal management notably should 'asymptomatic' bowel rotation anomalies undergo operation? The present study therefore sought to determine: (1) the risk(s) of volvulus in patients diagnosed with heterotaxy and (2) define morbidity associated with operation for 'asymptomatic' anomalies in a fragile patient cohort with co-existent congenital heart disease. Medical case record reviews of ALL heterotaxy patients born during January 1993-December 2013 and attending a UK paediatric centre were analyzed. Of a total of 92 patients, 16 (17.4%) cases underwent foregut imaging studies. Three examinations were performed in 'symptomatic' patients. Twelve studies reported 'abnormal anatomy' with only five patients undergoing surgical correction. No complication(s) were recorded after Ladd's operation to correct defects. A single fatality occurred within 30 days postoperatively from cardiac failure. In 87 patients in whom Ladd's operation was not undertaken, no single patient developed intestinal volvulus (median length of follow-up 27.2 months, total 446.1 person years). This study strongly supports a 'watchful waiting' policy for heterotaxy patients. Many children who ultimately die from heart disease may avoid unnecessary abdominal surgery.

Reducing CLABSIs Through Team Empowerment: A 67% Reduction

As a 250-bed regional pediatric medical center in New Orleans, Louisiana boasts a 36-bed Neonatal Intensive Care Unit (NICU) that experienced continual central line associated bloodstream infections (CLABSI) since January 2014. These infections were not associated with acuity, location within the unit, or a lack of adherence to basic infection control principles. By June 2014, it was determined that a more active approach was needed. In June 2014, a multidisciplinary team formed, including Infection Prevention, Quality Assessment and the NICU team to quickly and effectively tackle the infection rate. The team rapidly implemented strategic initiatives to include insertion and maintenance bundles, checklists, a dressing change team, a “buddy system” for tubing changes, use of sterile linens, chlorhexidine gluconate (CHG) bathing, daily assessment of device need with indication documented, a “kick the bucket” campaign, a “days since last CLABSI” poster, and root-cause-analyses from the Infection Preventionist (IP) for every infection. Using Excel, device days and infections were compared to before implementation (January to June 2014) and after (July to December 2014) to determine statistical significance of the strategies implemented. The adherence to the bundles, CHG bathing, and dressing changes was audited, with case reviews by the IP on any suspect or confirmed CLABSIs. The infections in NICU from January to June 2014 was compared to July – December 2014, with no statistical difference in device days. Process audits and case reviews showed excellent adherence to the initiatives, with staff feedback revealed a feeling of empowerment and in-control of preventing CLABSIs. By implementing bundle approaches and best practices to central line insertion and maintenance, the NICU experienced a 67% reduction in CLABSIs. This achievement has paved the way for the team to adopt these strategies house-wide.

Prevalence and Parental Awareness of Hearing Loss in Children with Down Syndrome

Background:To establish the prevalence of hearing deficit in children with Down syndrome (DS) in Hong Kong as measured by brainstem auditory evoked potentials (BAEP). The secondary objective is to examine the agreement between BAEP and clinical questioning in detecting hearing deficit in DS.Methods:Consecutive DS patients attending the Down's Clinic in a regional pediatric referral center were recruited into this cross-sectional study. BAEP data performed within 12 months were retrieved. The care-taker was interviewed with a structured questionnaire to detect any symptom of hearing impairment. BAEP findings and clinical questionings were compared in an agreement analysis using quadratic weighted kappa statistics.Results:Fifty DS patients (35 male, 15 female, mean age 11.70 years ± 5.74 standard deviation) were recruited. Eighteen patients (36.0%) were identified having hearing deficit by BAEP. Among patients with hearing impairment, 13 patients (72.2%) had a conductive deficit, and most have mild to moderate hearing loss. Five patients (27.8%) had sensorineural deficit and most have moderate to severe degree. Eight (44.4%) had bilateral hearing deficit. Care-takers of 13 patients (26.0%) reported symptoms of hearing impairment, with 9 (69.2%) having mild symptoms, 3 (23.1%) had moderate symptoms and 1 (7.7%) had severe symptoms. The weighted kappa was 0.045 (95.0% confidence interval − 0.138–0.229), indicating very poor strength of agreement between BAEP and clinical questioning. For patients with conductive hearing impairment, only 1 patients (7.7%) recalled history of otitis media.Conclusions:The estimated point prevalence of hearing impairment in Chinese DS children in Hong Kong is 36%. Our finding of poor strength of agreement between objective testing and symptom questioning reflects significant underestimation of hearing impairment by history taking alone. In view of the high prevalence and low parental awareness, continuous surveillance of hearing is mandatory for DS patients throughout childhood and adolescence.

G531(P) Improving the safety and quality of handover

Context This project aimed to improve handover for paediatric medical specialties, paediatric surgery and general paediatrics at a regional tertiary paediatric centre. As well as doctors of varying grade and specialty, others involved include the nursing outreach team and bed manager. Problem Handover occurs three times a day and with 50–80 complex patients it needs to be an efficient process ensuring patient safety and communication of essential appropriate information. Issues around the quality and safety of handover were highlighted from clinicians within the department, trainee feedback and the GMC survey. Assessment of problem and analysis of its causes Baseline measurements were obtained over 16 consecutive handovers. Measures included: start time, length of handover, number of bleep interruptions, time of specialty handover, and missed patients. Problems identified included: Late specialty handovers resulting in delays to commencing shifts Frequent non-urgent bleeps interrupting flow and causing distraction Patients not handed over in order meaning patients ‘missed’ Multiple late ‘corridor handovers’ These findings were presented to different stakeholders to address concerns, identify good practice and suggest areas for improvement. Suggestions included; introduction of a handover checklist, reminders on ward phones of protected handover times, and the introduction of a traffic light system to classify patients into an acuity category. Intervention Utilising small tests of change (PDSA cycles) we implemented sequential changes. For example a handover checklist was introduced at the start of each handover. Simple additions such as shutting the door gave clear non-verbal clues to people who were late. Stratifying patients according to traffic light acuity red (un-stable) amber (potentially unstable) and green (stable and on pathway) helped keep handovers focused. Strategy for change These changes were introduced and measured over an additional 16 handovers with continual feedback from junior doctors and outreach nurses. The consultant body was kept informed by the project lead. Measurement of improvement Measurements were undertaken over specific periods rather than continually. The project began in the quieter summer months with lower total patient numbers and the 3 rd data collection is from November during busier times on the unit. Effects of changes Several small changes have considerably improved the handover process. Verbal feedback has been really positive. Some of the initial changes have now been incorporated into the trust-wide computer system and are now used routinely in adult practice. We are continuing to measure variables and make changes. Uptake of some of the changes is variable (see results, Table 1), however as we reinforce successful changes and introduce handover education into induction, we hope to make adjustments standard procedure. Next steps are to develop a standardised structure for handover of patients according to acuity category. This will be linked to need for review and outreach involvement. Lessons learnt Getting buy-in from the consultant body and key stakeholders has been paramount. The senior lead empowering the juniors who are present on a daily basis to continue change when faced with those less willing to engage in a new process has been essential to success. Using regular feedback has enabled us to review improvements. We have been able to re-adjust changes on a short time scale, enabling us to reflect on the impact of our adjustments on the safety of handover. Message for others Simple rapid small changes have significantly improved the efficiency and safety of handover. Front line junior staff, empowered by more senior clinicians, have introduced these changes. Engaging the whole team is critical to sustained success. Change is a continual dynamic process and monitoring effects of interventions helps identify where further work is needed.

Hematological manifestation in HIV infected children.

To determine the common hematological abnormalities in HIV infected children and any association of these abnormalities with HIV disease severity. Cross-sectional study. Regional Pediatric ART centre, Medical College and Hospital, Kolkata, West Bengal, India, from November 2011 to November 2012. Children up to 12 years with confirmed diagnosis of HIV infection were clinically examined and tested for complete hemogram and CD4 count. Bone marrow study was done in selected patient depending on hemogram report. Children were divided in different stages according to WHO clinical staging. Each of the hematological parameters was assessed for any association with progression of disease. Fisher's Exact Test was used for determining the association between WHO clinical staging and abnormal blood parameters. P-value < 0.05 was taken as significant. Sixty nine percent of the study population was anemic; 47.37% (18/38), 66.67% (8/12), 71.43% (15/21) and 93.10% (27/29) of stage 1, 2, 3 and 4 respectively were anemic in the study population (p=0.001). Leucopenia was present in 34% (34/100) children. Neutropenia and lymphopenia was present in 19% (19/100) and 22% (22/100) children. Lymphopenia was present in 7.89% (3/38), 16.67% (2/12), 19.05% (4/21) and 44.83% (13/29) of patient with stage 1, 2, 3 and 4 respectively (p=0.020). Eosinophilia was present in 17% (17/100) and thrombocytopenia in 11% (11/100) children. 2 patients with stage 4 disease were with hypoplastic bone marrow. Anemia was the most common hematological abnormality in HIV infected children. Anemia and lymphopenia had a significant association with the stage of the disease.

An audit of anesthesia safety in a pediatric cochlear implantation program.

Approximately 50 children per year undergo cochlear implant surgery under the Scottish Cochlear Implant Programme at University Hospital Crosshouse, Kilmarnock. Many have significant comorbidities. Although this district general hospital has a high dependency unit, there is no pediatric intensive care unit (PICU). Children deemed likely to need PICU care are operated on at the local tertiary pediatric hospital in Glasgow, 25 miles away. To determine the safety of anesthesia for cochlear implant surgery in children at a district general hospital. Using the theater management system, we identified 306 cochlear implant procedures in children aged 16 years and under. A retrospective case note review was performed to determine demographic data and seek evidence of any anesthesia-related complications. Records for 168 children having 258 cochlear implant procedures were obtained. Forty percent of these children had one or more comorbidities, including 11.9% who were ex-premature babies. Twenty-two complications or incidents were noted, the majority of which were minor. Two cases had potentially serious complications and one of these was abandoned. This gives a serious complication rate of 0.8%. Undeclared upper respiratory tract infections was most likely the greatest preventable cause of complications. Seven cases were referred to the regional pediatric center during the study period. Anesthesia for cochlear implants in children can be safely carried out in a district general hospital setting. Appropriate safeguards should be in place to refer complex cases which may require PICU to a tertiary pediatric center.