Pediatric Tertiary Care Research Articles

Statistical analysis plan for the SQUEEZE trial: A trial to determine whether septic shock reversal is quicker in pediatric patients randomized to an early goal-directed fluid-sparing strategy vs. usual care (SQUEEZE)

BackgroundThe SQUEEZE trial is a multicentred randomized controlled trial which seeks to determine the optimal approach to fluid resuscitation in paediatric septic shock. SQUEEZE also includes a nested translational study, SQUEEZE-D, investigating the value of plasma cell-free DNA for prediction of clinical outcomes. ObjectiveTo present a pre-specified statistical analysis plan (SAP) for the SQUEEZE trial prior to finalizing the trial data set and prior to commencing data analysis. DesignSQUEEZE is a pragmatic, two-arm, open-label, prospective multicentre randomized controlled trial. SettingCanadian paediatric tertiary care centres. ParticipantsPaediatric patients with suspected sepsis and persistent signs of shock in need of ongoing resuscitation. Sample size target: 400 participants. InterventionsThe trial is designed to compare a fluid-sparing resuscitation strategy to usual care. Main outcome measuresThe primary outcome for the SQUEEZE trial is the time to shock reversal (in hours). The primary outcome analysis will assess the difference in time to shock reversal between the intervention and control groups, reported as point estimate with 95% confidence intervals. The statistical test for the primary analysis will be a two-sided t-test. Secondary outcome measures include clinical outcomes and adverse events including measures of organ dysfunction and mortality outcomes. ResultsThe SAP presented here is reflective of and where necessary clarifies in detail the analysis plan as presented in the trial protocol. The SAP includes a mock CONSORT diagram, figures and tables. Data collection methods are summarized, primary and secondary outcomes are defined, and outcome analyses are described. ConclusionsWe have developed a statistical analysis plan for the SQUEEZE Trial for transparency and to align with best practices. Analysis of SQUEEZE Trial data will adhere to the SAP to reduce the risk of bias. RegistrationClinicalTrials.gov identifiers: Definitive trial NCT03080038; Registered Feb 28, 2017. Pilot Trial NCT 01973907; Registered Oct 27, 2013.

Benzodiazepine Use Disorder Observed and Diagnosed in a Tertiary Care Pediatric Specialty Clinic: A Descriptive Retrospective Chart Review

Benzodiazepine Use Disorder Observed and Diagnosed in a Tertiary Care Pediatric Specialty Clinic: A Descriptive Retrospective Chart Review

India’s Silent Struggle: A Scoping Review on Postpartum Depression in the Land of a Billion Mothers

Background: Postpartum emotional issues, including postpartum blues, postpartum psychosis, and postpartum depression (PPD), affect many mothers worldwide. The prevalence of postpartum blues ranges from 300 to 750 per 1,000 mothers, while postpartum psychosis has a prevalence of 0.89–2.6 cases per 1,000 births. PPD affects 100–150 new mothers per 1,000 births, and its prevalence can go above 25% globally. Depression in mothers can have long-lasting impacts on children and the next generation, affecting their growth, development, and relationships. However, the condition of PPD is frequently misdiagnosed, and women who suffer from it do not receive treatment. There is a lack of solid systematic evidence that looks at the overall burden of PPD and the risk factors that are associated with it in India. The awareness of PPD is critical in managing the symptoms and seeking professional support, and studies are needed to evaluate and assess the situation in India. Methodology: This study is a systematic literature review with a scoping review approach aimed at providing existing evidence on the awareness and prevalence of PPD in India. The search strategy for the electronic bibliographic search included a list of related terms and factors of awareness and prevalence of PPD. The search encompassed six prominent databases. The assessment tools used in studies from 2012 to 2023 study the factors using the Postpartum Depression Literacy Scale (PoDLiS) and the Edinburgh Postpartum Depression Scale, which measure the awareness and prevalence of PPD. Results: The study found a significantly low volume of studies conducted in India to determine the prevalence of PPD. The materials or studies accessible are hospital-based research with a minimal number of samples. The reported prevalence rate of postpartum depression (PPD) in India varies across different studies, ranging from 4% to 48.5%. Among mothers who gave birth either naturally or by cesarean section in a hospital setting, one study reported the lowest prevalence rate (4%). The prevalence of PPD among women in India is estimated to be 18% based on the average score across all research. A study that evaluated the moms in the community found that PPD was prevalent in new mothers at a rate of 21.5%. There are three studies, in particular, that focus on how aware people are of PPD. Two studies found that 54% of the family members of postpartum moms and women undergoing tertiary pediatric care are aware of PPD. Discussion: Many studies point to the lack of social support as a significant risk factor for mental health complications after delivery. History of depression, anxiety, adverse life events, partner abuse, low economic status, complications at childbirth, and a traumatic childbirth experience are some of the associated factors identified in the studies. Studies have also shown that women who undergo a cesarean section have a higher risk of developing PPD than those with a vaginal delivery.

Enteral Ketamine for Status Epilepticus in Children with Epilepsy

BackgroundApproximately 10% to 20% of children with epilepsy experience status epilepticus (SE), and children with seizure clustering are at higher risk. Ketamine is growing in use for SE. This study examines the efficacy and safety of enteral ketamine in the treatment of convulsive status epilepticus (CSE) characterized by refractory seizure clusters and nonconvulsive status epilepticus (NCSE) in children with epilepsy. MethodsPatient charts were reviewed retrospectively. Children with epilepsy aged one to 21 years presenting in SE and treated with enteral ketamine between September 1, 2021 and September 1, 2022 at a pediatric tertiary care center were identified. Resolution or reduction in seizure frequency within 48 hours, clinical presentation, endotracheal intubation, hospitalization duration, side effects, and readmission were assessed. ResultsNine patients aged two to 21 years were identified. Six patients presented in CSE characterized by recurrent seizures, and three patients presented in NCSE. Five patients had genetic epilepsies, including PCDH19- and MECP2-related epilepsy. Seven patients had resolution or reduction in seizures within 48 hours of ketamine initiation. Two patients were intubated. Hospitalization duration ranged from one to 34 days. Three patients reported side effects. Three patient readmissions with early ketamine treatment had equal or shorter hospitalizations. ConclusionsEnteral ketamine may prove an effective, well-tolerated option for treatment of convulsive and nonconvulsive SE in children with epilepsy, including genetic epilepsies, and may prevent intubation and shorten hospitalization time.

Impact of medication dosage on Helicobacter pylori eradication rates among pediatric patients.

Helicobacter pylori rates of eradication to common first-line regimens continue to decline globally. Prescription of the appropriate medication dosage is an important consideration, particularly in the pediatric population due to medication weight-based dosing. Limited data is available on the impact of guideline-recommended weight-based dosing on the successful eradication of H. pylori in children. Retrospective study of patients with histologic evidence of H. pylori from two pediatric tertiary care centers in New England. We excluded patients who were not treated or those missing eradication data. We compared the eradication rates of patients prescribed recommended weight-based dosages, duration, and frequency of treatment with those who were not. One hundred forty-four patients were included. The overall eradication rate was 73.6% (106/144). All treatment regimens were properly prescribed for 14 days. There was a high rate of improper weight-based dosing: proton pump inhibitor (PPI) 31.2% (45/144), amoxicillin 31.7% (39/123), metronidazole (MET) 19.4% (12/62), clarithromycin (CLA) 23.9% (22/70), tetracycline 50% (6/12), bismuth 26.1% (6/23). When PPIs were properly weight-dosed, there was a 78.8% eradication rate that dropped to 62.2% with suboptimal dosing (p = 0.036, OR: 2.26, CI: 1.04-4.87). When amoxicillin was properly weight-dosed, successful eradication was achieved in 81% versus only 53.8% when improperly dosed (p = 0.002; OR: 3.64, CI: 1.58-8.37). There was no statistically significant impact on eradication rates with improper weight-based dosing of MET, CLA, tetracycline, or bismuth. Proper weight-based dosing of amoxicillin and PPI is important for the successful eradication of H. pylori among children in the New England area.

Preparing Future Pediatric Care Providers with a Clinical Informatics Elective.

Clinical informatics (CI) has reshaped how medical information is shared, evaluated, and utilized in health care delivery. The widespread integration of electronic health records (EHRs) mandates proficiency among physicians and practitioners, yet medical trainees face a scarcity of opportunities for CI education. We developed a CI rotation at a tertiary pediatric care center to teach categorical pediatric, pediatric-neurology, and medicine-pediatric residents foundational CI knowledge and applicable EHR skills. Created in 2017 and redesigned in 2020, a CI rotation aimed to provide foundational CI knowledge, promote longitudinal learning, and encourage real-world application of CI skills/tools. Led by a team of five physician informaticist faculty, the curriculum offers personalized rotation schedules and individual sessions with faculty for each trainee. Trainees were tasked with completing an informatics project, knowledge assessment, and self-efficacy perception survey before and after rotation. Paired t-test analyses were used to compare pre- and postcurriculum perception survey. Thirty-one residents have completed the elective with their projects contributing to diverse areas such as medical education, division-specific initiatives, documentation improvement, regulatory compliance, and operating plan goals. The mean knowledge assessment percentage score increased from 77% (11.6) to 92% (10.6; p ≤ 0.05). Residents' perception surveys demonstrated improved understanding and confidence across various informatics concepts and tools (p ≤ 0.05). Medical trainees are increasingly interested in CI education and find it valuable. Our medical education curriculum was successful at increasing residents' understanding, self-efficacy, and confidence in utilizing CI concepts and EHR tools. Future data are needed to assess the impact such curricula have on graduates' proficiency and efficiency in the use of CI tools in the clinical workplace.

Advancing allergy diagnosis in children through component resolved diagnostics in a pediatric tertiary care hospital

Advancing allergy diagnosis in children through component resolved diagnostics in a pediatric tertiary care hospital

Individualized Care Delivery for Children With Autism and Related Disabilities Undergoing Overnight Video Electroencephalography (EEG): One Hospital's Experience With a Coordinated Team Approach.

Background and Purpose: Children with developmental disabilities have increased risk of epilepsy and need for overnight video electroencephalographic (EEG) monitoring. However, video EEGs have historically been considered difficult to complete for this population. An autism support service at a pediatric tertiary care hospital implemented a coordinated team approach to help children with developmental disability tolerate overnight video EEGs. The project included completion of a caregiver-report preprocedure questionnaire that then was shared with the multidisciplinary team and used to create individualized care plans. The current study aims to describe rates of video EEG completion and need for lead placement under general anesthesia among children with autism and related disabilities who received these supports. Methods: Rates of video EEG completion and general anesthesia use were analyzed for children referred to the support service between April 2019 and November 2021. Results: A total of 182 children with developmental disability (mean age = 10.3 years, 54.9% diagnosed with autism) met inclusion criteria. 92.9% (n = 169) of children successfully completed EEG (leads on ≥12 hours). Only 19.2% (n = 35) required general anesthesia for video EEG lead placement. The majority (80.2%) of parents (n = 146) completed the preprocedure questionnaire. Video EEG outcomes did not differ based on completion of the questionnaire. Parent-reported challenges with communication and cooperation were associated with shorter video EEG duration and greater use of general anesthesia. Conclusions: These findings suggest that most children with developmental disability can complete video EEG with sufficient support. Preprocedure planning can identify children who would benefit from additional accommodations. Further research is necessary to clarify which supports are most helpful.

Implementation of the Mind Youth Questionnaire (MY-Q) for routine health-related quality of life screening of adolescents with type 1 diabetes in a large tertiary care center.

Prevalence of diabetes distress and mental health comorbidities among adolescents with type 1 diabetes (T1D) is high. Despite recommendations for routine psychosocial risk assessment, there is little guidance for their implementation. This study aims to describe the implementation and baseline outcomes of the Mind Youth Questionnaire (MY-Q), a validated psychosocial screening tool for health-related quality of life (QoL) including mood, among adolescents living with T1D. Adolescents aged 13-18 years completed the MY-Q from October 1, 2019-April 1, 2023. Baseline characteristics, MY-Q results including categories flagged positive (noting possible areas of concern), debrief duration, and frequency of social work or mental health referral were collected and analyzed using descriptive statistics. A total of 343 adolescents (mean age 15.3 years; 52 % female) completed a baseline MY-Q. Median overall MY-Q debrief time (IQR) was 10.0 min (6.0, 20.0). About 290 (84.5 %) adolescents had at least one of seven categories flagged, most commonly "Family" (61 %). About 30 % of adolescents had "Mood" flagged, and 2.9 % of adolescents were referred to mental health following debrief. Without the need for additional resources, implementation of the MY-Q in a pediatric tertiary care diabetes clinic successfully identified QoL issues and mental health concerns among adolescents with T1D.

Prospective Analysis of Acute Encephalitis Syndrome: Clinical Characteristics and Patient Outcomes in a Tertiary Care Pediatric Setting

Background: One of the most frequent neurological emergencies in pediatrics, central nervous system infections cause a considerable amount of death and morbidity. Especially in newborns, the symptoms are frequently modest, therefore a strong index of suspicion is needed to make the diagnosis. Inadequate or delayed treatment may result in fatalities or other severe consequences.  Objective: To ascertain the frequency, clinical characteristics, and etiological makeup of kids hospitalized in tertiary PICU due to acute encephalitis syndrome. Results of kids referred to tertiary PICUs with acute encephalitis symptoms.  Study Design: Hospital based prospective study.  Participants: Children with AES from one month up to 18 years of age admitted in PICU of hospitals.  Intervention: Thorough clinical assessments were completed, and blood samples will be sent for various baseline biochemical analyses. In every instance, samples of blood and urine were sent for sensitivity and culture while adhering to strict aseptic protocol. In every incidence of fever with altered sensorium, neuroimaging and CSF analysis will be carried out.The history, clinical examination, and pertinent laboratory investigations are used to determine the etiology of AES.  Results: Out of the one hundred cases that were examined, five had J.E., thirty had rickettsia, twenty had dengue, one had varicella, twelve had COVID-19, five had measles, four were pyogenic, one had tuberculosis, twelve had ADEM, and nine were undiagnosed. A total of 45 patients were lost to follow-up throughout the follow-up period. Of the patients, 16 had hearing loss, 10 had speech loss, 15 had extra pyramidal abnormality, 21 had behavioral abnormality, and 21 had cranial nerve impairments.  Conclusion: AES is a persistent public health issue that requires immediate attention, as well as cooperation and support from other sectors. Strengthening primary health care is urgently needed to provide access to both routine and emergency care, both of which are essential for better results.

Value-based comparison of ambulatory children with respiratory diseases in an emergency department and a walk-in clinic: a retrospective cohort study in Québec, Canada

ObjectiveTo compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases.DesignA retrospective cohort study.SettingThis study was conducted from...

Foreign body aspiration in children: our pediatric tertiary care experience.

Inhalation of a foreign body is a real emergency in pediatric age and requires prompt diagnosis and treatment to reduce mortality. The objective of this study is to analyze clinical and radiological details, types, and localization of foreign bodies in patients conducted or to our hospital with suspected inhalation. We conducted a retrospective analysis of all cases of foreign body inhalation admitted to our Pediatric Emergency Room between January 2009 and June 2022. 171 patients were included in the study. In 83 patients, the FB was detected. The mean age of presentation was 2.3years (SD: ± 2). Cough (73%) and unilateral reduced breath sound (51%) were the most common clinical symptom and clinical sign. The most frequent localization was the right main bronchus (43%). The foreign bodies retrieved were vegetable (83%), of which peanut was the most common. Chest radiographs were normal in 25%. The mean duration of hospitalization was 5days (± 2.9). Complications such as pneumothorax were seen in two cases. Foreign body inhalation represents a true pediatric emergency and still a challenge in clinical practice. The best way to manage it is an early diagnosis and removal by fully trained staff.

The Landscape of Resource Utilization After Resuscitation of 22-, 23-, and 24-Weeks’ Gestation Infants

ObjectiveTo compare estimated healthcare resources needed to care for 22 through 24 weeks’ gestation infants. Study designThis multicenter, retrospective cohort study included 1,505 live in-born and out-born infants 22 through 24 weeks’ gestational age at delivery from six pediatric tertiary care hospitals from 2011 through 2020. Median neonatal intensive care unit (NICU) length of stay (LOS) for each gestational age was used as a proxy for hospital resource utilization, and the number of comorbidities and medical technology use for each infant were used as estimates of future medical care needs. Data were analyzed using Kruskal-Wallis with Nemenyi’s post hoc test and Fisher’s exact test. ResultsOf the identified newborns, 22-week infants had shorter median LOS than their 23- and 24-week counterparts due to low survival rates. There was no significant difference in LOS for surviving 22-week infants compared with surviving 23-week infants. Surviving 22-week infants had similar proportions of comorbidities and medical technology use as 23-week infants. ConclusionsCompared with 23- and 24-week infants, 22-week infants did not use a disproportionate amount of hospital resources. 22-week infants should not be excluded from resuscitation based on concern for increased hospital care and medical technology requirements. As overall resuscitation efforts and survival rates increase for 22-week infants, future research will be needed to assess the evolution of these results.

Aspartate aminotransferase and alanine aminotransferase elevation in suspected physical abuse: Can the threshold to obtain an abdominal computed tomography be raised?

Identification of abdominal injury (AI) in children with concern for physical abuse is important, as it can provide important medical and forensic information. Current recommendations are to obtain screening liver function tests (LFTs) in all children with suspected physical abuse and an abdominal computed tomography (CT) when the aspartate aminotransferase (AST) or alanine aminotransferase (ALT) is >80 IU/L. This threshold to obtain an abdominal CT is lower than general trauma guidelines, which use a cutoff of AST >200 IU/L or ALT >125 IU/L. This was a retrospective review of children aged 0 to 60 months at a single pediatric tertiary care center who were evaluated for physical abuse and had AST or ALT >80 IU/L. Subjects were then stratified into two groups: midrange (AST ≤200 IU/L and ALT ≤125 IU/L) and high-range (AST >200 IU/L and/or ALT >125 IU/L) LFTs. Abdominal CTs were performed in 55% (131 of 237) of subjects, 38% (50 of 131) with midrange LFTs and 62% (81 of 131) with high-range LFTs. Abdominal injury was identified in 19.8% (26 of 131) of subjects. Subjects with AI were older than those without AI (mean [SD] age, 18.7 [12.5] vs. 11.6 [12.2] months; p = 0.009). The highest yield of abdominal CTs positive for AI was in the group with high-range LFTs with signs or symptoms of AI at 52.0% (13 of 25; 95% confidence interval, 31.3-72.2%). The negative predictive value of having midrange LFTs and no signs or symptoms of AI was 100% (95% confidence interval, 97.0-100%). Our data suggest that abdominal CT may not be necessary in children being evaluated for physical abuse who have AST ≤200 IU/L and ALT ≤125 IU/L and do not have signs or symptoms of AI. This could limit the number of abdominal CTs performed. Diagnostic Test/Criteria; Level IV.

The Utilization of Computed Tomography in the Pediatric Emergency Department for Patients With Ventriculoperitoneal Shunts.

Introduction Despite all the advantages of computed tomography (CT) scanning, there is a significant concern due to the rising use of CT scans in children with ventriculoperitoneal (VP) shunts. High doses of radiation are absorbed by patients, raising their chance of acquiring cancer. Evaluating a potential VP shunt malfunction is a frequent encounter in the pediatric emergency room, often necessitating the utilization of a CT scan. This study aims to recognize and quantify the utilization of CTscans in an emergency setting for pediatric patients with a clinical suspicion of VP shunt malfunction. Methods This retrospective chart review was conducted on patients who visited the emergency department with suspected VP shunt malfunction in a pediatric tertiary care hospital (King Abdullah Specialist Children Hospital), Riyadh, Saudi Arabia. The study included the files of children between the years 2018 and 2019. Results A total of 119 children were included; the main indication for VP shunt insertion was congenital hydrocephalus at 46.8% (n=52). The median number of CT scans done per patient was seven (IQR=3-9). CT findings were abnormal among 55.6% (n=60). The univariate analysis examining the impact of different factors on CT findings showed an association between an abnormal CT finding and female gender (P=0.017), younger age (P=0.03), and the presence of a cerebral cyst (P=0.001); however, subsequent multivariate analysis was not significant for any of these factors.Twenty-two point three percent (n=25) of the patients required neurosurgical intervention, and the associated factors with neurosurgical intervention included changes in activity level (P=0.04), weakness (P=0.004), and altered mental status (P=0.001). Conclusion Children with VP shunts are susceptible to significant radiation exposure through the utilization of CT scans whenever they present to the ER with suspected shunt malfunction during their lifespan, which puts them at risk of radiation-related complications, such as cancers. CT imaging remains a helpful tool aiding physicians in making accurate decisions. However, in this study, almost half of the children had unremarkable CT findings. Thus, it is imperative to rationalize its use by establishing tailored guidelines that delineate the appropriate circumstances warranting its application.

Granulocytapheresis Donor Deferrals Pattern at a Pediatric Tertiary Care Centre in Northern India.

Granulocyte transfusion is used to manage refractory infections in patients with severe neutropenia. One of the main challenges in providing granulocyte products is the availability of a suitable donor. This study was designed to analyse deferral patterns to appropriately create a pool of granulocyte donors. A retrospective analysis was done to study the deferral pattern among donors who presented to our pediatric tertiary care hospital during the last year (August 2022-August 2023) for granulocyte apheresis. The donor selection criteria are like any apheresis donor in addition to having appropriate veins in both the arms and donor providing consent for mobilization (Dexamethasone). A total of 181 donors with a mean age of 31.3 ± 6.7years (males 93.9%) were screened for granulocytapheresis. 61 donors (33.7%; 51 Male 10 Female) were deferred. Common reasons for deferral were poor venous access (34.4%), low platelets (24.5%), the difference in blood group between donor and recipient (19.6%), low hemoglobin (1.6%) and transfusion-transmitted infection (all HBV) reactivity (6.5%). Our study highlights a higher rate of donors deferred for granulocyte donations when compared to whole blood donations. Analysing the deferral pattern can help us identify appropriate donor groups to motivate and recruit for granulocyte donations.

Same-Day Discharge for Pediatric Hemithyroidectomy Patients: Evaluating Safety and Barriers to Discharge.

Hemithyroidectomy is often performed in the pediatric population for indeterminate or benign thyroid nodules. Prior studies confirmed the safety of same-day discharge for adults undergoing hemithyroidectomy or total thyroidectomy, but this has not been studied thoroughly in the pediatric population. Our goal was to determine differences in pediatric patients undergoing hemithyroidectomy who were admitted versus discharged for complications or factors to support same-day discharge. Retrospective cohort. Pediatric tertiary care hospital. This was a retrospective study of pediatric patients (0-18 years of age) undergoing hemithyroidectomy at a pediatric tertiary care hospital from 2003 to 2022. Perioperative variables and outcomes were gathered via manual chart review. One hundred five pediatric patients who underwent hemithyroidectomy were identified. Ninety (86%) patients were admitted postoperatively, and 15 (14%) were discharged the same day. There were no differences in patient demographics, including age (P = 0.29) distance from the hospital (P = 0.08) or benign versus malignant pathology (P = 0.93). Surgical time in same-day discharges was significantly shorter (P = 0.0001; 138.6 minutes, SD = 66.0) versus admitted patients (204.2 minutes, SD = 48.6) Hemostatic agents were used more in same-day discharges at 53.3% versus 4.5% (P = 0.0001). Perioperative complications occurred in 2 (2.2%) admitted patients compared to none in the same-day discharge (P = 1.0). There were no readmissions within 30 days for same-day discharges. In pediatric patients undergoing uncomplicated hemithyroidectomy, same-day discharge appears appropriate for those with shorter surgical times and intraoperative use of hemostatic agents with no readmissions or complications in those discharged the same day.

The Frequency, Severity, and Risk Factors of Hickman CatheterRelated Complications in Pediatric Cancer Patients: A Single-Center Experience from Bosnia and Herzegovina.

This study aimed to identify the frequency, severity, and risk factors associated with Hickman catheter-related complications in children with hemato-oncological malignancies at the largest pediatric tertiary care unit in Bosnia and Herzegovina. A cross-sectional study was conducted on a cohort of pediatric cancer patients who underwent Hickman central venous catheters (CVCs) between January 2019 and December 2022. Mechanical, infectious, and thrombotic Hickman catheter-related complications were evaluated and analyzed. We also investigated possible risk factors associated with these complications. Seventy-one Hickman CVCs were inserted in 68 children (44 boys and 24 girls) at a mean age of 6.9 ± 4.6. Forty (58.8%) children had hematological malignancies and 28 (41.2%) solid cancers. The median follow-up after Hickman CVC insertion was 190 days (95% CI [160-212]) for 12 644 catheter days. During follow-up, 10 (14.1%) mechanical, 7 (9.9%) infectious, and 1 (1.4%) thrombotic complications were recorded (0.8, 0.48, and 0.08 for mechanical, infectious, and thrombotic complications per 1000 catheter days, respectively). A slightly higher incidence of complications was recorded in children with hematological malignancies (1.59 per 1000 catheter days) compared with children with solid cancers (1.22 complications per 1000 catheter days). Using Hickman CVCs for long-term venous access in infusional chemotherapy for pediatric cancer patients is safe but is associated with significant morbidity.

Improving Adolescent Psychosocial Assessment through Standardized Patient Simulation: An Interdisciplinary Quality Improvement Initiative.

Adolescent suicide and mental illness have increased at alarming rates. Healthcare professionals report a lack of skill and confidence in obtaining adolescent histories and managing confidential care due to limited training in residency. Nursing professional development practitioners face challenges of adequately preparing interdisciplinary healthcare providers to assess, identify, and intervene at all points of contact with adolescents. To increase the confidence in clinical communication skills and clinical competency, and to increase the number of social work referrals related to modifiable risk factors for adolescent patients, a Texas pediatric tertiary care center utilized standardized patient (SP) methodology to supplement traditional clinical experiences with communication-focused education based on the Home, Education, Eating, Activities, Drugs, Sexuality, Suicidality, and Safety (HEEADSSS) interviewing. This quality improvement (QI) pilot demonstrated the benefits of utilizing standardized patient methodology in communication-focused education based on the HEEADSSS interviewing. Following the SP simulations, confidence in clinical communication skills increased by 13%, clinical competency in performing comprehensive psychosocial interviews increased by 11%, use of HEEADSSS increased by 64%, and social work referrals increased by 89%. This interdisciplinary SP interviewing simulation pilot was beneficial in improving the 36 physician and nursing residents' ability to conduct psychosocial assessments for risk factors of suicidality among adolescents.

Laboratory stewardship perceptions and testing patterns at a pediatric tertiary care center.

Despite stewardship efforts, laboratory testing overuse persists across medicine. To understand laboratory stewardship perceptions and testing patterns at a tertiary care pediatric hospital so that we could identify potential improvement opportunities. An electronic survey exploring laboratory stewardship was sent to all pediatric medicine resident and staff physicians. Laboratory testing data were also assessed for patterns of testing and overuse. The survey response rate was 54% (43/80). The results indicated good familiarity with stewardship but poor familiarity with testing specifics (eg, cost). A mobile reference application was the most preferred quality improvement intervention, and online modules were the least desired. Overuse was apparent, with as many as 53% of laboratory tests being repeated within 7 days and only half of repeated tests subsequently yielding abnormal results. Altogether, the data we collated demonstrated poor understanding of laboratory stewardship and substantial repeat testing with few abnormal results. These study findings suggest that laboratory stewardship is lacking at our center, and that multiple improvement opportunities exist.