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  Sepsis: Triage Triggers, Outcomes Quicker

  Rylee Ainge, Mackenzie Flaws, Natalie Heim, Emily Herndon, Hayley Norris, and Amy Scott

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  Shortening the Duration of Antimicrobial Therapy in Uncomplicated Skin and Soft Tissue Infections

  Alicia Daggett and Brandi Missel

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  Significant Loss of Blood Amino Acids and Free Carnitine in Newborns Receiving Continuous Renal Replacement Therapy (CRRT)

  Uttam Garg, Marita Thompson, Bradley A. Warady, and Vimal Chadha

  Background
  
  

  •Newborns with acute kidney injury (AKI) or end-stage kidney disease (ESKD) often receive prolonged CRRT when the early initiation of peritoneal dialysis is either contraindicated or unable to be performed. •These patients often receive total parenteral nutrition (TPN) to meet their nutritional goals. •Little to no information exists on the loss of blood amino acids (AA) and carnitine during CRRT in these patients. •The objective of this study was to determine the amino acids and carnitine losses in newborns receiving prolonged CRRT and TPN. Material and Methods
  
  •Three newborns who received prolonged (> 2 weeks) CRRT and TPN were included in the study. Blood and CRRT effluent were simultaneously collected from these patients. •The effluent specimens were collected over 8-12 hours and the results were extrapolated to 24 hrs. Plasma was separated from blood for the analysis of 30 amino acids and free carnitine. •Amino acids in plasma and CRRT effluent were analyzed using an amino acid analyzer which uses ion-exchange chromatography and post-column ninhydrin derivatization (Biochrom System). Free carnitine was determined by HPLC-tandem mass spectrometry (HPLC-MS/MS) using flow injection, electrospray ionization and precursor ion scan. •The total amount of amino acids and carnitine received by each patient was calculated from the amino acids concentrate and carnitine added to the TPN solution. •The sieving coefficients (SQ) for each measured amino acid and carnitine was determined, while the amino acids and carnitine losses were calculated as mg/day, and as a percentage of the intake. Results •The blood flow was 50 mL/min for all three cases, and the CVVHDF clearance ranged from 68 – 115 mL/kg/hr (1.4 – 3.2 L/hr/1.73 m2). •The AA intake varied from 3.8 – 4.5 gm/kg/day. Carnitine intake was 20 mg/kg/day in two patients and 50 mg/kg/day in the third. •The SQ for all essential AAs was >0.8; in contrast, acidic AAs (glutamic and aspartic acid) had a SQ 0.84 and carnitine losses were 80% of the daily intake. •At the given high protein intake, all three patients achieved a positive N2 balance ranging from 0.45 to 0.59 gm/day.
  Conclusions
  
  •During CRRT, most of the AAs (including all essential AAs) are freely filtered and the quantity lost is influenced by the CRRT clearance. •In our very small sample of patients, positive nitrogen balance was achieved in all three patients with a very high (3.8 – 4.5 gm/kg/day) protein intake. •As carnitine is rapidly and freely filtered during CRRT, these patients are at risk of significant carnitine depletion. •The impact of serum AA and carnitine losses on nutritional outcome in patients with renal disease receiving CRRT is not known at this time. •Additional studies are needed to determine if these patients require special AA formulations and the degree of carnitine supplementation in their TPN to account for the AA and carnitine losses that regularly occur.

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  Sustainability and Outcomes of a Standardized Aminoglycoside Induced Ototoxicity Monitoring Algorithm

  Claire Elson, Christopher M. Oermann, Michelle Weltman, and Ellen Meier

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  Teaching High School Seniors about Transitioning to Adult Healthcare

  Christine Clune, Teresa Hickam, and Adrienne Olney

  This poster describes an educational intervention consisting of two classroom sessions to teach high school seniors how to successfully transition to adult care. Topics covered included the ability to fill out medical forms, when to contact one's doctor and where to get medical care when the doctor's office is closed, how health care privacy changes at age 18, the need for health insurance, the need to keep medical records, etc.

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  The Headache Champion Program

  Courtney Wellman and Kristin Allender

  BACKGROUND

  Approximately 10% of school age children suffer from migraines, making migraines one of the top five health problems experienced by youth today

  School nurses often are the first healthcare provider seen by youth with migraine; visits to the school nurse for headaches amounted to one-third of the enrolled student population in a large local school district. (see reference)

  Empowering school nurses through education and resources to identify and manage migraines therefore may have significant benefits to children with migraines and their families.

  OBJECTIVE

  To improve migraine care in the community through establishing a headache specialist mentorship program for select school nurses (the "Headache Champion Program")

  PROJECT OVERVIEW

  Figure 1 provides an overview of the project model

  Applications were accepted from interested, self-nominated school nurses within the region served by the headache specialist clinical program; those selected for the program demonstrated a commitment to learning and a passion for improving the lives of headache sufferers

  The selected school nurses were matched with a headache specialist "mentor" for monthly telephone conversations aimed at increasing knowledge and empowering advocacy for youth with headaches; the headache specialist also provided additional resources for school and home use (e.g., www.headachereliefguide.com)

  Nurses received a certificate of completion and a letter they could mail to families in the school district making them aware of the nurse's participation

  RESULTS & CONCLUSIONS

  Upon completion of the program, school nurse "Headache Champions" were empowered by knowledge to better care for school age children who suffer from migraines.

  Feedback from school nurse participants was positive (e.g., "Being able to talk to a person is so much better than just receiving information. . . so educational")

  Interest in the program has triipled since its roll out and continues in 2017-18 school year

  Future efforts include an urgent access headache clinic, to which students may be directed, and continued growth of the mentorship program.

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  The Lifecycle of a K-card: Improving Data Collection While Improving Bundle Reliability

  Tara Benton, Barb Haney, Lacey Bergerhofer, Susan Burns, Yolanda Ballam, and Kaitlyn Hoch

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  The Relationship Between Iron Status, Limb Movements, and Sleep Architecture in Children

  David G. Ingram MD, Gaylyn Perry MD, Zarmina Ehsan MD, and Baha Al-Shawwa MD

  Background

  •Iron status is an important aspect of the evaluation of children with excessive limb movements during sleep. •While there is clear data in adults to support this relationship, the data in children is less well established. •We evaluated the association between iron status and limb movements during sleep in a large pediatric sample. Methods •This is a retrospective analysis of a single institution sleep program looking at all patients who underwent overnight polysomnogram and ferritin test within 24 hours of doing the sleep study between January 2015 and October 2017. •Those with sleep apnea (Central Apnea Index >5/hr or Obstructive Apnea Hypopnea Index >2/hr) were excluded. Results •There were a total of 418 patients who qualified for inclusion. Mean age was 5.6 years (range 0–19 years). •Overall, higher ferritin level was significantly associated with increasing age, increasing N2 sleep, lower REM sleep and lower single limb movement index but did not correlate with periodic limb movements of sleep. •It appears that ferritin level at 30 nanograms per milliliter is the cutoff to make a difference in improving single limb movements (7.2+/-2.7 vs 7.9 +/- 3.6 for above and below 30 ng/ml, respectively). •In multivariate regression modelling including single limb movement index and age, the association between ferritin and limb movements was no longer significant. Conclusions •Overall, there is a weak correlation between ferritin and single limb movements during sleep. •However, it appears that age is an important possible confounding factor in the complex relationship between and iron status and limb movements in children.

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  The Relationship Between Vitamin D Status, Limb Movements, and Sleep Architecture in Children

  David G. Ingram MD, Gaylyn Perry MD, Zarmina Ehsan MD, and Baha Al-Shawwa MD

  Background
  
  •Vitamin D deficiency has recently been posited as an important factor in the pathogenesis of restless leg syndrome.

  •We evaluated the association between vitamin D deficiency and limb movements and sleep architecture in a pediatric sample.

  Methods

  •This is a retrospective analysis of a single institution sleep program looking at all patients who underwent overnight polysomnogram and 25-OH vitamin D within 60 days of doing the sleep study between January 2015 and October 2017. •Those with sleep apnea (Central Apnea Index >5/hr or Obstructive Apnea Hypopnea Index >2/ hr) were excluded. Results •There were a total of 83 children who qualified for inclusion. Mean age was 7.0 years (range 1–17 years). •Overall, higher Vitamin D level was significantly associated with increasing N3 sleep (r=0.267, p=0.015), but was not significantly associated with other sleep parameters including limb movements. •In multivariate regression modelling including Vitamin D and age, the association between vitamin D and N3 sleep percentage remained significant (B=0.212, SE=0.102, p=0.04). Conclusions •Overall, there is a weak positive correlation between vitamin D and N3 sleep, even independent of age. •In contrast, there was no association between any limb movement parameter and Vitamin D status. •Further investigation is needed to better define the role of Vitamin D in sleep physiology.

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  Utilizing a Situation Awareness Huddle Tool to Decrease Code Blue Events

  Matthew B. Johnson, Lisa Carney, Cheryl Powers, Bradley Bishop, Natalie Masters, Becky Paulsen, Andrea Raymond, and Paul N. Bauer

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  Venous Thromboembolism Risk Stratification via Electronic Medical Record Classification

  Shannon L. Carpenter, Laura Miller-Smith, Brittney Hunter, Ashley Duty, Justin Sheets, Yuri Tupa, and Kate Gibbs

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  Implementation of a Multi-Institution, Multistate Cystic Fibrosis Transition Program

  Christopher M. Oermann, D Polineni, A Andrews, A Moog, Paula Capel, T Bomstedt, Ellen Meier, and J Mermis

  Background: Children’s Mercy-Kansas City (CMKC) is an independent children’s hospital in Kansas City, MO. Its CF Care Center (CFCC) provides care for 250 patients. The University of Kansas Medical Center (KUMC) is an academic medical center in Kansas City, KS. Its CFCC includes adult/pediatric programs (230/50 patients). Interactions between CMKC and KUMC were minimal prior to 2013. CMKC provided care through adulthood despite CF Foundation mandates requiring transition of patients aged 18-21 years. Transition only occurred per patient request. Methods: The CMKC CFCC underwent restructuring and staff expansion in 2013-2014. KUMC underwent staff expansion in 2012, adding a nurse, respiratory therapist (RT), social worker (SWO, and dietitian. These changes fostered improved communications and provided a foundation for developing a more robust transition program (TP). Elements of the TP included SW to SW driven initiation of quarterly meetings (none occurred prior to 2013), chaperoned tours of KUMC ambulatory and inpatient care areas, creation of a “Welcome Packet” by KUMC, and expanded inclusion of KUMC at the CMKC CF Family Education Day. In 2013, KUMC staff were invited to participate in breakout sessions and Q&A sessions with parents to help address concerns related to the RP and care at KUMC. KUMC also created co-clinic coordinator positions in 2013 with the SW and RT. This streamlined the TP by assigning education to the SW and logistics (medical records and scheduling to the RT. The KUMC and CMKC teams worked together to create a TP Worksheet and Checklist to endure that needed records were available. KUMC also developed a peer-to-peer program from transitioning and pre-transition patients to connect with adults already receiving care at KUMC. Results: The number of patients transitioned each year varied. The largest number of patients transitioned in a given year followed changed discussed above. The age range at transition narrowed between 2010 and 2016, with all patients transitioning by age 21 in 2015. Mean age at transition decreased. Conclusions: The unique situation at CMKC and KUMC resulted in impediments to a functional TP. Barriers included payer issues related to MO and KS Medicaid, a culture of “patient-driven” transition and insufficient staffing at both institutions. Reorganization of the CMKC CFCC and improved staffing at both institutions led to an improved TP, with transition of all adult patients from CMKC to adult CF programs. Communication and sustaining a “Culture of transition” are key elements in the development of a successful TP.

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  Knowledge Base of Adolescents with Congenital Heart Disease

  Mark Gelatt, Julie Martin, Jennifer A. Marshall, Jennifer Panuco, Jenea Schmidt, and Pamela Finn

  Introduction:

  Most congenital heart disease [CHD] is diagnosed and treated in early childhood with parents responsible for decision-making. The adolescent assumes this role in preparation for transition to an adult congenital heart program. We studied the knowledge base of our adolescent CHD patients and their parents.

  Methods:

  Established CHD patients, >11 y.o. and their parents, were independently surveyed in the outpatient clinic. Participation was voluntary. Cardiomyopathy, electrophysiology and transplant patients were excluded. Scores were assessed as full, partial or incomplete.

  Results:

  Most (98% parents; 83% adolescents) reported that their cardiologist had provided education. Adolescents provided a full (49%) and partial (15%) medical name and full (32%) and partial (35%) description of their condition. Older adolescents performed better (p<0.005). Parents scored better, regardless of patient age (p<0.005). Presence of prior surgery/intervention made no difference. Patients undergoing last surgery >11 y.o. scored better than those with surgery only when younger or without surgery (p<0.05) [data not shown]. Patients with mild unrepaired or surgically repaired shunt lesions (ASD, VSD, PDA), and their parents, were much less able to name their lesion than those with left heart lesions (aortic stenosis, coarctation, mitral valve disease), tetralogy of Fallot, TGA/TAPVR or palliated single ventricles, but similar in ability to at least partially describe the defect (p<0.005). In this more affected population, the ability to fully name the defect (81/134; 60%) far exceeded the ability to fully describe it (37/134; 28%; p<0.005).

  Conclusion:

  Only one-half of adolescents are able to name their cardiac defect, and one-third are able to adequately describe the anatomy. Older adolescents, those with a more recent history of surgery and those with more complex defects perform better. Parents are much more knowledgeable than their children. A strong emphasis should be made on educating adolescents with CHD as they transition to adulthood.

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  Library Services

  Brenda R. Pfannenstiel MALS, MA, AHIP; Courtney Butler MLS; Keri Swaggart MLIS, AHIP; and Megan Molinaro BA

  Describes activities and resources provided by the Library Services department at Children's Mercy Kansas City.

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  A Month at The Lake Clinic - Cambodia

  Mara Horwitz

  Describes a global health learning experience in Cambodia on floating clinics that serve residents of remote villages of the Tonie Sap Lake and Stung Sen River.

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  A Month in Manila

  Robin M. Lund

  Describes a global health learning experience at Philippines Children's Medical Center in Manila.

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  An Expanded Role for Nurses in Laboratory Utilization

  Marilyn S. Hamilton, Rangaraj Selvarangan, Michele Fix, and Lynn E. Shriver

  Introduction: The majority of laboratory testing errors occur in the pre-analytical stage, including specimen collection. Children provide special challenges including small blood volumes, small veins, and an inability to cooperate. We describe collaboration between laboratorians and nursing staff to improve specimen collection and the reliability of test results.

  Methods: We identified three areas for improvement: 1) Volume of blood for culture, 2) Urine collection, and 3) Appropriate blood collection through a line. Base line data was established. Guidelines for specimen collection were updated. Nurse members of the Laboratory Utilization Committee developed educational tools.

  Results: Nursing education was effective at improving collection of blood for culture and IV fluid contamination of blood specimens, processes where the nurse was the collector. There was no improvement in the urine culture contamination rate, a process which involves the patient and/or family members.

  Discussion: Nursing participation in laboratory utilization efforts provides an opportunity to address specimen collection issues. Nurses are also excellent resources concerning work flow in clinics and inpatient floors. They also actively participate in the education of young doctors.

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  Application of the Multi-Facet Rasch Model to Validate Chief Residents Survey: A Two-Year Study

  Kadriye O. Lewis and Ross Newman

  This study compares the Chief Resident candidates' characteristics and leadership qualities within and across two years and further validates the Chief Resident peer selection instrument.

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  Exploring Pediatrics in the Philippines

  Taylor Hansen

  Describes her learning experience in the Philippines with the Jose Fabella Memorial Milk Bank, Fabella's Kangaroo Mother Care Unit, and Talisay Health Center in 2017.

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  Focus Groups as a Method to Build Library Services and Partnerships Across the Institution

  Courtney R. Butler and Megan Molinaro

  BACKGROUND: Children's Mercy is an independent, non-profit, 367-bed pediatric health system with multiple clinic locations and a strong focus on research. It offers a pediatric residency program and over 37 subspecialty fellowship programs.

  New initiatives go through many steps from conception to implementation. The focus of this case study is to describe how gathering feedback from stakeholders during proposal development provided valuable insight, secured stakeholder collateral to support requests for administrative approval and funding, and marked the beginning of new productive institution-wide partnerships.

  PROJECT STAGES:
  Identify Needs
  Identify Stakeholders
  Evaluate Software
  Conduct Focus Groups
  Develop Fair Market Analysis/Executive Summary
  Convene Task Forces for Implementation

  GATHERING FEEDBACK: Gathering feedback is an important part of project development. Surveys can be a convenient and effective option, but they risk low response rates with stilted, fill-in-the-blank answers. Candid feedback was imperative for this initiative to ensure that all critical factors were being considered.

  CONCLUSIONS: Using focus groups proved effectual in improving the project design. Feedback provided the opportunity to refine the proposal and highlighted issues that had not been sufficiently investigated such as interoperability with existing systems. It also revealed interest in additional use cases, such as the ability to host educational materials. Furthermore, the interactions resulted in stakeholders willing to advocate for the project and to participate in its development and implementation and better prepared Library Services to address administrative concerns. These newly built partnerships will allow future projects and service improvements to build off this project's success.
  
  

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  Global Health Elective: Swaziland, Africa

  Jane Duong

  Describes her learning experience providing care with the Baylor International Pediatric AIDS Initiative (BIPAI) in September 2017.

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  Global Health Experience in Swaziland

  Anik Patel

  Describes a global health learning experience at the Baylor Center of Excellence in Swaziland, where diagnosis and treatment of HIV/AIDS and TB, along with maternal health, women's health, and adolescent care are provided.

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  Hematuria Without Microalbuminuria

  Angela Ferguson, Vimal Chadha, Amy Wiebold, and Uttam Garg

  Background
  
  

  Microabubiminuria is a condition in which small amounts of albumin are excreted in the urine without overt nephropathy. Based on the

  American Diabetic Association classification, microalbuminuria is defined as urinary excretion of albumin of 30–300 mg per 24 hours or 20–200 mcg/min or 30–300 mcg/mg creatinine. Various conditions such as diabetes, hypertension, and impaired renal tubular reabsorption can lead to microalbuminuria. Microalbuminuria is an indicator and predictor of the development of overt nephropathy. If identified and treated early, overt nephropathy can be prevented and averted. Proteinuria and hematuria are the two most common urinary abnormalities encountered during routine urinalysis. In renal dysfunction, it is common to encounter isolated proteinuria without hematuria. Also, when using a dipstick, it is not uncommon to encounter mild isolated hematuria without proteinuria. Since dipstick and protein precipitation methods lack sensitivity for trace proteinuria, immunoassays are used for the measurement of trace amounts of albumin in urine. It is commonly believed that hematuria is always associated with proteinuria or microalbuminuria. Based on this belief, many laboratories cancel microalbuminuria testing if the urine dipstick is positive for blood. We encountered several urine samples that were dipstick positive for blood but negative for microalbuminuria based on the American Diabetic Association definition.
  Materials and Methods
  
  

  To study this aspect more objectively, urine samples with a typical creatinine concentration were spiked with 5, 10, 20 and 50 uL of whole blood (total volume 10 mL). Using a dipstick, these aliquots were tested for blood and protein, and then analyzed for creatinine and microalbumin on a chemistry analyzer. The urine dipstick analysis was performed on the Clinitek 500 Urine Chemistry Analyzer, while the urine creatinine and microalbumin were performed on the Ortho Vitros 5600 using the Vitros CREA slides and Randox microalbumin reagent.
  Results
  
  

  Figure 1. Visual analysis of urine specimens

  Urine specimen A (Fig. 1 A and B) and urine specimen B (Fig. 1 C and D) were aliquoted and spiked with 0 (Blank), 5,10, 20 and 50 uL of whole blood. Total volume of 10 mL. Aliquots of each were also spun down to visualize the red blood cells present (Fig. 1 B and D).
  Table 1. Urine characteristics
  Color, clarity, blood and protein were assessed by dipstick and read by the Clinitek analyzer. Creatinine and microalbumin were measured by the Ortho Vitros 5600.

  Conclusions

  •These findings suggest that samples with hematuria may be negative for microalbumin, and therefore, laboratories should not automatically cancel microalbumin testing if a sample is dipstick positive for blood. •A better strategy may be to test the sample for protein using a dipstick and cancel the test for microalbumin only if the sample is positive for greater than trace protein.

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  Investigating Program Directors' Milestone Assessment Practices in Graduate Medical Education

  Kadriye O. Lewis, Susan B. Hathaway, J F. Knapp, Denise Bratcher, and Douglas Blowey

  The purpose of this study is to investigate the current assessment practices as well as identify the needs and challenges of the Program Directors in implementing ACGME's Milestones for assessment in graduate medical education at a pediatric hospital. The ultimate outcome of this study will be to fairly deliver our support and services to all programs equally providing expertise/consulting, guiding, mentoring/advising, and distributing resources.

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  Pre-Implementation of a Fontan Post-Operative Clinical Pathway: Summary of 2016 PDSA Cycles

  Sarah M. Lagergren, Bryan Beaven, Suma Goudar, and Megan Jensen

  Background/Introduction: Post-operative hospitalization for the Fontan procedure tends to have an extended hospital length of stay (LOS). From 2013-2014, the average LOS at Children’s Mercy for the Fontan procedure is 14 days, whereas the U.S. national reported average is 11 days. Post-operative management of this patient population is often caregiver dependent. It has been theorized that developing a more standardized post-operative management regimen tailored specifically toward the unique physiology of Fontan patients may be able to improve outcomes and decrease LOS.

  Methods: A review of literature was performed and revealed three pediatric institutions have published their post-operative Fontan care guidelines. Common elements from these care guidelines were identified and then trialed in 2016 on our post-operative Fontan population. Three patients were included in four individual PDSA cycles. Adherence to each intervention was tracked and information gathered regarding potential issues.

  Results: Use of supplemental oxygen prior to chest drainage tube removal had 100% adherence and no harm or negative side effects (such as nosebleeds, or impeding ability to ambulate) reported. Restriction of fluids had a 33% adherence rate with IV fluids started or IV fluid boluses administered over the 80% restriction in 2/3 patients. Following a standardized diuretic regimen had 100% adherence with no negative patient outcomes. Obtaining central access within 48 hours post-operatively via a PICC line had 100% adherence.

  Conclusion: By performing individual PDSA cycles prior to full implementation of a post-operative clinical pathway, potential areas of concern were able to be identified and addressed or disproved. The Fontan clinical pathway was fully implemented for 2017 with plans to complete another full PDSA cycle.