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  Improving Access to Spanish COVID-19 Resources at a Children’s Hospital

  Fernando Zapata, Romina Barral, July K. Jean Cuevas, Lines Vargas Collado, Nicholas Clark, Amanda Montalbano, and Cristina Fernandez

  Background: The COVID-19 pandemic disproportionately impacts Spanish-speaking communities. COVID-19-related health information is overall more available in English than Spanish. From May to August 2020, Spanish COVID-19-related resources on our institution’s website had an average of 2954 views/month compared to 48573 views/month to the English COVID-19-related resources.
  
  
  Objective:
  Our project aim was to increase the percent of page views for Spanish COVID-19-related resources on our institution’s website from 5.7% of the total views to the COVID-19-related pages, to 20% from September 2020 through June 2021.
  
  
  Design/Methods: An ethnically diverse, multidisciplinary team including physicians proficient in Spanish as well as our institution’s information technology, marketing, and public relations departments used improvement methodology to identify root causes using a driver diagram to guide interventions. Outcome measure was percent of page views to the Spanish COVID-19 website out of all COVID-19 website views (Spanish and English). The total number of Spanish COVID-19 website views served as the process measure. Plan-Do-Study-Act cycles were developed: 1) All COVID-19 information was translated to Spanish (September); 2) Recorded and aired educational video on a local Spanish television station regarding Spanish COVID-19 resources available on the website (October); 3) Addition of QR Code linking to the Spanish COVID-19 website on clinic discharge paperwork (November); 4) Rerun video on local Spanish television station, with a new Holiday Tips and Safety video and a direct link added to their website (December). Run and control charts were utilized to assess improvement over time.
  
  
  Results: Process measure improved from a mean of 2954 monthly views to 3803 during the intervention period while at the same time English COVID-19 website page views decreased from a mean of 48558 to 40321 monthly page views (Fig 1). During the intervention period, outcome measure displayed special cause improvement from 5.7% to 8.7% of total COVID-19 page views arising from Spanish COVID-19 websites (Fig 2).
  
  Conclusion(s): QI methodology revealed a lack of Spanish resources on our institution’s website and underutilization in accessing them. Interventions included improving the quality and content and disseminating the information internally and externally. The project has been successful in increasing traffic to Spanish COVID-19 resources. QI methodology can be used to help close gaps in pandemic-related health disparities.

  Presented at the 2021 PAS Virtual Conference

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  Improving the Rate of Emergency Department Physician Pre-Procedure Time-Out Documentation for Deep Sedation and Cutaneous Abscess Incision and Drainage

  Arjun Sarin, Nikita Sharma, and Shobhit Jain

  Background: The pre-procedure time-out, an important safety measure to verify patient identity and accuracy of a planned procedure, and Joint Commission requirement, is not documented consistently by physicians in our emergency department (ED). Deep sedation and cutaneous abscess incision and drainage (I&D) are two high-risk procedures performed in the ED, supporting the use of a time-out in this setting. Between June 2018 and May 2019, a pre-procedure time-out was documented in the physician procedure note of the electronic medical record (EMR) for 75% of deep sedations, and 94% of I&Ds.
  
  
  Objective: We aimed to improve ED physician pre-procedure time-out documentation for deep sedation (ketamine and/or propofol) from 75% to 90%, and I&D from 94% to 98% by July 2020.
  
  
  Design/Methods: Our ED is part of a free-standing, tertiary children’s hospital, comprised of two separate locations across two states, with a combined annual volume of 125,000 visits. We analyzed one year of baseline data for deep sedations and I&Ds performed in both locations, followed by weekly reports from November 2019 to July 2020. We provided education to the physicians regarding the history and importance of the pre-procedure time-out, monthly reminders and updates, as well as individualized feedback for deficient documentation. We optimized EMR procedure notes for deep sedation and I&D, and incentivized the project with American Board of Pediatrics Maintenance of Certification (MOC) credit, as well as a financial bonus. For cases of concurrent deep sedation and I&D, we expected the time-out be documented in both of the independent procedure notes, and measured these accordingly.
  
  
  Results: During the study period we averaged 100 deep sedations and 25 I&Ds per month. Physician documentation of a pre-procedure time-out improved from 75% to 100% for deep sedation, and from 94% to 99.3% for I&D. The improvements remained sustained for five months without additional intervention. All physicians were eligible for the financial bonus; 40 met MOC credit requirements.
  
  Conclusion(s): A pre-procedure time-out may reduce the likelihood of avoidable patient harm and is practical to perform in a busy ED setting. Using quality improvement methodology, we increased ED physician pre-procedure time-out documentation for deep sedation and I&D through education, feedback, and systems improvement. Future studies may quantify the effects on patient safety and examine the use of similar interventions for other ED procedures.

  Presented at the 2021 PAS Virtual Conference

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  Learning From the Past: A Novel and Sustainable Initiative to Reducing Unplanned Extubations in a Level IV Neonatal Intensive Care Unit

  Yonatan Kurland, Dena Hubbard, and Eugenia K. Pallotto

  Background: Unplanned extubations (UPEs) are a cause of significant morbidity and mortality in neonates. Multiple successful interventions had been previously implemented in our NICU including standardized endotracheal tube (ETT) securement procedures, bedside checklists, and multi-disciplinary debriefing. In our unit greater than 65% of UPEs occur in neonates under 1.5kg who are particularly sensitive to small adjustments in tube position. We designed a novel approach to reducing UPEs in this patient population.

  Objective:
  
  
  Design/Methods: We hypothesized that increased awareness of historical ETT position would both prevent unnecessary ETT position adjustments and encourage prophylactic adjustments to adjust for significant weight gain or loss. In December 2019, we implemented a novel intervention to provide readily accessible graphs of historical ETT tube position in each neonate with corrected gestational age <32 weeks. In successive>cycles, education was provided to all members of the multidisciplinary team, the graph was refined into a readily printable format and changes were made to the unit workflow to ensure updated graphs were available at the bedside at every shift.
  
  
  Results: UPE rates in 2019 prior to the intervention were 1.0 events per 100 vent days. In the 12 months following the intervention and refinements, the UPE rate decreased to 0.76 per 100 vent days. Balancing measures included the frequency of tube position changes, tube re-taping and chest x-rays which did not change or showed a decrease over the study period.
  
  Conclusion(s): By providing ready access to information on historical ETT position, our unit fostered an environment of communication & safety with a sustained and decreasing rate of unplanned extubations.

  Presented at the 2021 PAS Virtual Conference

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  Medical Neglect: Trends in Reporting Practices and Patient Characteristics

  Danielle Horton, Emily Killough, and Mary Moffatt

  Background: Medical neglect has significant consequences on child health and well-being. Improved processes for defining, recognizing, and reporting medical neglect are needed, however there is limited published data on the subject. Insight into patient characteristics and current reporting practices will help identify areas for intervention to improve outcomes for children at risk for medical neglect.
  
  
  Objective: To describe characteristics of children identified for concern of medical neglect and trends in reporting of cases to child protective services (CPS).
  
  
  Design/Methods: We performed a 1-year retrospective descriptive study of subjects < 18 years of age at a single, tertiary-care, academic pediatric institution for whom a Patient at Risk (PAR) assessment was completed exclusively for the concern of medical neglect. The PAR is a unique institutional process by which health professionals and social workers document concerns for child maltreatment. Medical records were reviewed for data regarding demographics, medical history, health care utilization and psychosocial risk factors. The role of the initiating provider and healthcare setting in which the PAR was recorded were also obtained.
  
  
  Results: Of 270 children with a PAR completed for medical neglect concerns, 97.4% were reported to CPS. PARs were most frequently initiated in the ambulatory (60.7%) setting by physicians (43%) or social workers (28.5%). Missed ambulatory appointments were common, with 62.2% of subjects having more than 5 missed appointments since establishing care. Chronic medical conditions were present in 80% of subjects. Over half (53%) of subjects had prior known involvement with CPS and 20% of subjects had a prior PAR completed for concern of medical neglect. Subjects were primarily African American (40%) or Caucasian (38.9%) and the majority were publicly insured (80.4%). Over half (59.6%) of subjects had at least 1 of 5 psychosocial risk factors addressed in PAR assessments (caregiver substance abuse, mental health issues, incarceration; intimate partner violence; transportation or financial challenges).
  
  Conclusion(s): Concerns for medical neglect are most frequently identified in the ambulatory care setting. Chronic medical conditions and psychosocial risk factors that may create a barrier to care are common. Data informed next steps include systemic monitoring of missed ambulatory clinic appointments and design of a standardized process to improve consistency of diagnosis and intervention in cases of medical neglect for children with chronic medical conditions.

  Presented at the 2021 PAS Virtual Conference

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  Multimodal Pain Control in Common Neonatal Surgeries: Post-operative Pain Protocol Reduces Opiate Exposure and Side Effects

  Jamesia Donato, Nefertari Terrill-Jones, Ashley K. Sherman, Warren Teachout, Stephanie Prince, Alexandra Oschman, Daphne Reavey, Darian Younger, and Tamorah R. Lewis

  Background: Opioids are the primary post-operative (post-op) analgesic in neonates. Side effects include hypotension, apnea and ileus. Previous studies show IV acetaminophen decreases opiate need in specific populations including cleft palate repair, cardiac surgery. The effect of IV acetaminophen as part of a post-op pain algorithm is not known in common neonatal surgical procedures.
  
  
  Objective: To determine if (a) a post-op pain algorithm including IV acetaminophen and (b) IV acetaminophen exposure reduces cumulative opioid requirements in neonates undergoing common surgeries in the NICU.
  
  
  Design/Methods: This is a retrospective cohort study comparing cumulative post-operative opiate exposure between infants with common surgeries in two cohorts: pre-pain algorithm (2013-2015, “PRE”), post-pain algorithm (2016-2018, “POST”), and also between infants who received post-op IV acetaminophen versus did not. Cumulative doses in IV Acetaminophen and opioids were calculated for each patient in the72 hours post-op. Pain scores, respiratory depression, hypotension, time to extubation, time to first stool, and time to enteral feeds were secondary outcomes. Wilcoxon Rank Sum tests were used for outcome comparisons amongst groups.
  
  
  Results: 690 infants met inclusion criteria. 306 (44%) patients were PRE and 384 (56%) POST. In the entire cohort, 202 patients (29%) received IV acetaminophen post-operative and 488 (70.7%) did not. PRE and POST median 72 hours opiate exposures were 0.56 mg (IQR 0-1.4) and 0.18 mg (IQR 0-0.82) respectively, p <0.01. Acetaminophen vs. non-Acetaminophen recipients had median opiate exposure of 0.30 mg (IQR 0-1.10) and 0.33 mg (IQR 0-1.2) respectively, p = 0.6245). Post-operative hypotension was 46.6% in PRE and 26.4% in POST (p <0.01); 27.9% and 38.5% in acetaminophen versus non-acetaminophen respectively (p = 0.01). Acetaminophen recipients had significantly higher pain scores (p <0.01). Median hours intubated was less in POST (22.3 hr, IQR 8.1-38.9) vs. PRE (25.8, IQR: 17.7-44.1); p < 0.01. Time to first stool was similar amongst all groups.
  
  Conclusion(s): Implementation of a post-op pain algorithm in the NICU significantly reduced cumulative opioid exposure. Hypotension and intubation time were reduced with acetaminophen exposure. With an increase in the percentage of elevated pain score in the group receiving IV acetaminophen, addressing additional system factors is needed for optimal postoperative pain treatment.

  Presented at the 2021 PAS Virtual Conference

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  Not-so-apparent Mixing Lesions: Late Presentation Of Cardioembolic Stroke

  Amulya Buddhavarapu, Christopher Mathis, William Gibson, and Sanket Shah

  Background: Multiple levels of inter-atrial shunting can rarely present late in life with dyspnea and embolic stroke from effects of bidirectional shunting.

  Case: A 55-year-old male with history of a patent foramen ovale, atrial fibrillation and embolic stroke presented with worsening fatigue and dyspnea at rest. Echocardiogram showed mildly reduced ventricular function with severe right heart dilation. On transesophageal echo, the coronary sinus (CS) was severely dilated with a persistent left superior vena cava (LSVC). A stress test showed no perfusion defects. CT angiography showed an absence of right SVC and a single LSVC connecting to the CS. There was partial anomalous pulmonary venous connection of the left upper pulmonary vein to the LSVC. The left lower pulmonary veins connected to the left atrium (LA) but largely drained indirectly to the right atrium via a defect at the LSVC-CS junction. The right pulmonary veins returned normally to the LA.

  Decision‐making: Catheterization revealed pulmonary overcirculation with pulmonary to systemic flow ratio [Qp:Qs] of 2:1. Surgery was preferred over percutaneous intervention for the repair of atrial septal defects and redirection of left upper pulmonary venous return to the left atrial appendage. The patient improved significantly following surgery.

  Conclusion: Multimodality imaging can help accurately diagnose venous anomalies and create three-dimensional models instrumental in procedural/surgical planning.

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  Online Echocardiography Modules for Pediatric Cardiology Fellows

  Sarah Studyvin, Doaa Aly, Laura Kuzava, Tyler Johnson, Alison Samrany, Nitin Madan, and Sanket Shah

  Background: Adequate echocardiographic (echo) education is integral to successful cardiology training. Online education is proven to be effective in other specialties, but pediatric echo training data are lacking. Our aim was to design and assess the role of a novel online module-based curriculum to enhance pediatric cardiology fellows’ echo education.

  Methods: Four interactive modules, focused on principles and interpretation of a normal echo, were delivered to fellows. Content included high quality 2D and 3D echo clips (Fig 1A) as well as interactive quizzes (Fig 1B) and could be accessed from a phone, tablet, or computer. All fellows completed pre- and post-tests, validated by independent expert imagers, and surveys.

  Results: 100% of fellows (n=7) participated in the pilot study. Test scores improved after completing the modules, and most fellows maintained a higher score at 4-weeks, suggesting good knowledge retention (Fig 1C). Self-assessed confidence in echo knowledge and interpretation, as assessed on a numeric scale, also improved (Fig 1D).

  Conclusion: Online microteaching modules can provide a valuable adjunct to traditional echo education in cardiology fellowships. Our digital, phone-accessible curriculum was well received by fellows and was associated with an objective and subjective improvement in their understanding and interpretation of a normal echo. Further expansion of such modules will be beneficial in the evolving era of virtual education in the face of the COVID-19 pandemic

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  Outpatient Antimicrobial Stewardship Programs in Children’s Hospitals: Status, Needs, Barriers

  Rana El Feghaly, Elizabeth Monsees, Alaina N. Burns, Brian Lee, Ann L. Wirtz, Adam L. Hersh, and Jason Newland

  Background: Antimicrobial stewardship programs (ASPs) are an essential tool to combat the increasing threat of antibiotic resistance. ASPs traditionally reside in acute care settings with a focus on inpatient prescribing. However, in 2016, the Centers for Disease Control and Prevention affirmed the importance of outpatient ASP through its 4 core elements. Incorporation of these elements requires time, personnel, and funding, which may not be available in many institutions.
  
  
  Objective: This study aimed to evaluate the current state of outpatient ASP in a large network of children’s hospitals and inform a programming agenda.
  
  
  Design/Methods: This cross-sectional study used an investigator-developed survey to assess current resources, interventions, and obstacles of outpatient ASP. We invited institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient collaborative (SHARPS-OP), which includes 54 sites from the United States and 2 from the United Kingdom. We used descriptive statistics to examine institution characteristics, current outpatient ASP work, and elucidate collaborative goals.
  
  
  Results: Forty-five sites participated achieving an 80% (45/56) response rate. Only 5 sites (11%) had allocated support for outpatient ASP, although 42 (95.6%) had allocated support for inpatient ASP (Table 1). The most widely used ASP interventions included toolkits (57.8%), education (46.7%), quality improvement projects (37.8%), research (27.8%), and electronic medical record features (27.8%) (Table 2). Time was identified as the biggest barrier to outpatient ASP (91%) followed by financial support (53%), development of meaningful reports (51.1%), and administrative support (44.4%). The most important goals of the collaborative included benchmarking and developing clear metrics for pediatric outpatient ASP (Table 3). Optional comments were provided by 93% of respondents indicating multiple areas of program needs which were condensed into 6 themes (Table 4) primarily focused on securing operational support (36%) and strengthening data analysis (31%). Likewise, data analysis was the most frequently cited request for collaborative discussion.
  
  Conclusion(s): Most institutions had robust acute care support and appreciated the urgent need to address outpatient antibiotic use. Only a small number of participants had allocated support to secure the progression of outpatient ASP with data analysis being a universal program need.

  Presented at the 2021 PAS Virtual Conference

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  Parental Health Literacy and Acute Care Utilization in Children with Medical Complexity

  Emily J. Goodwin, Joy L. Solano, Jessica L. Bettenhausen, Ryan Coller, Adrienne G. DePorre, Rupal Gupta, Kayla R. Heller, Lauren Jones, Leah Jones, Kathyrn Kyler, Ingrid Larson, Laura Plencner, Margaret Queen, Timothy Ryan Smith, Tyler Smith, Jacqueline M. Walker, Margaret Wright, Isabella Zaniletti, and Jeffrey D. Colvin

  Background: Inadequate health literacy, defined as inadequate ability to find, understand and use health information is associated with poor health outcomes and high health care costs. Children with medical complexity (CMC) have high rates of acute care utilization. Understanding parental health literacy in CMC and its relationship to acute care utilization may inform interventions designed to lower utilization.
  
  
  Objective: To examine parental health literacy for CMC and determine its association with acute care utilization.
  
  
  Design/Methods: In this single-site cross-sectional study, 250 parents of CMC completed a self-administered survey (response rate of 66.1%). CMC were included if they had a complex chronic condition (CCC) and were enrolled in the CMC primary care clinic or received primary care at the study site. The main predictor was parental health literacy as measured by the validated Single Item Literacy Screener (SILS). SILS measures the frequency of needing assistance when reading medical information. Table 1 lists the categorization of SILS responses in our original and post hoc analyses. Main outcomes were acute care utilization defined as annual emergency department (ED) visits, hospitalizations, and associated costs. We examined bivariate associations with the X2 test and multivariable associations with a generalized linear model with log link and time from first to last episode as offset, adjusting for demographic and clinical characteristics.
  
  
  Results: About 94% of parents had adequate health literacy (Table 2). Adequate health literacy increased with the number of CCCs (p<0.01). When using the traditional categorization of SILS responses, there were no differences in acute care utilization by health literacy in the bivariate (Table 3) and adjusted analyses (Table 4). In the post-hoc adjusted analyses, parents with Low-Adequate health literacy had seven times greater annual ED costs compared to parents with High-Adequate health literacy. They also had 35% more annual hospitalizations and 64% greater hospitalization costs compared to parents with High-Adequate health literacy (Table 4).
  
  Conclusion(s): Parents of CMC had high rates of adequate health literacy. Future studies should determine if this is common in parents of CMC or unique to our study population. We found few associations with acute care utilization. Future studies should examine if additional aspects of health literacy (e.g., listening, speaking, numeracy) not included in the SILS better predict acute care utilization.

  Presented at the 2021 PAS Virtual Conference

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  Pediatric Resident Reflections from a Non-Medical Home Visit of a Child with Medical Complexity

  Emily J. Goodwin, Sheryl Chadwick, DeeJo Miller, Kathryn Taff, and Amanda Montalbano

  Background: Pediatric residents typically only interact with patients and families in healthcare settings which limits the opportunity to fully understand the patient and family experience. Encounters with children with medical complexity (CMC) that only relate to illness or health monitoring can anchor residents to false preconceptions and limit their ability to practice patient- and family-centered care (PFCC). The core principles of PFCC include acknowledging patient and family expertise and strengths, encouraging their input, and appreciating the value of their observations and perceptions.
  
  
  Objective: To explore how a home visit program with patients and families serving as faculty could instill the principles of PFCC in pediatric residents.
  
  
  Design/Methods: This mixed methods study used grounded theory to qualitatively analyze 10 years of retrospective data from resident reflections facilitated by parents on staff following a non-medical home visit with a CMC. Transformative and social learning theories were used to structure the output into 6 themes: frame of reference, observations, realizations, disorienting dilemmas, reflections and discourse, and shifts in their world view.
  
  
  Results: The 132 reflection sessions were analyzed using a 90-word code book to capture 11,194 codes in 3,741 excerpts. Responses early in the reflection sessions most often were more factual statements representing their prior attitudes and experiences, literal observations from the home visit, and discovery of new knowledge. By the end of the sessions the excerpts represented challenges to their preconceptions, shifts in their frames of reference, and comments about how this experience will alter or impact their future practice (Table 1). The most common codes reflected the PFCC principles including “normalcy,” “family centered care,” and “medicine beyond the bedside.”
  
  Conclusion(s): Immersion experiences solidify or alter resident frames of reference; however, a facilitated group debrief may deepen the learning opportunity and lead to a variety of realizations that promote broader reflections and discourse. Parent facilitated reflection sessions following a non-medical home visit instilled concepts that are difficult to teach within clinical settings.

  Presented at the 2021 PAS Virtual Conference

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  Perinatal exposure to Interleukin-6 (IL-6): a model to study influence of developmental insult on susceptibility to chronic kidney disease (CKD)

  Tarak Srivastava, Robert E. Garola, Varun Chandra Boinpelly, Jianping Zhou, Daniel P. Heruth, Mohammad Rezaiekhaligh, M. Farhan Ali, Lakshmi Priya, Uri Alon, Trupti Joshi, Yuexu Jiang, Ellen T. McCarthy, Ram Sharma, Madhulika Sharma, Gregory Vanden Heuvel, Virginia J. Savin, Pramod B. Mahajan, and Mukut Sharma

  Background: CKD and obesity are marked by elevated pro-inflammatory cytokines, including IL-6. Pregnant obese women are associated with 1.5- to 2-fold increase in serum IL-6, newborns with smaller kidney/body weight ratio, kidney anomalies and increased susceptibility to CKD. Maternal IL-6, but not TNFα or IL-1β, can cross the placental barrier and enter fetal compartment.
  
  
  Objective: We examined the role of (a) maternal injection of IL-6 during mid-gestation, similar to levels observed in pregnant obese women, on kidney development as a specific molecular surrogate of gestational inflammation and (b) IL-6 on glomerular filtration barrier.
  
  
  Design/Methods: Pregnant mice received IL-6 (10 pg/g ip) on alternate days from E12.5 to end of gestation while the control pregnant mice received normal saline. Following euthanasia, newborn kidneys were fixed in 10% formalin or OCT, or used to isolate RNA or protein lysate. We used in vitro albumin permeability assay to study the effect of IL-6 on filtration barrier.
  
  
  Results: Mid-gestational administration of IL-6 (10 pg/g) to pregnant mice resulted in newborns with lower body (p<0.001) and kidney (p<0.001) weights [Figure i]. Histomorphometry showed decreased nephrogenic zone width (p=0.039), increased numbers of mature glomeruli (p=0.002), and pretubular aggregates (p=0.041) [Figure ii]. Immunostaining for podocyte markers showed increased number of mature glomeruli (p<0.001), LC-MS for CpG DNA methylation revealed increased 5mC levels (p<0.05), and Western blotting showed upregulated JAK2/STAT3 (p<0.05) [Figure iii]. RT-qPCR Array analysis of cell-cycle and apoptosis genes also suggested accelerated maturation. In vitro studies using isolated rat glomeruli showed that IL-6 (0.01-5 pg/mL) significantly increased glomerular albumin permeability (p<0.001) which was blocked by pretreatment with anti-IL-6 antibody suggesting its direct effect on the glomerular filtration barrier. IL-6 caused derangement of the actin cytoskeleton and upregulation of pJAK2/pSTAT3 in murine podocytes that maintain the glomerular barrier function.
  
  Conclusion(s): Perinatal exposure to IL-6, a surrogate of maternal inflammation, resulted in small kidneys with accelerated maturation and upregulated JAK-STAT signaling. IL-6 injures the glomerular filtration barrier. We propose to use this animal model to study susceptibility to CKD in adult offspring to determine the long-term effects of the growing incidence of maternal obesity, obesity and CKD across the globe.

  Presented at the 2021 PAS Virtual Conference

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  Peripartum Antibiotics Induce Dysbiosis and Predispose the Neonatal Gut Towards Inflammation

  Alain Cuna, Marianne N. Nsumu, and Venkatesh Sampath

  Background: Broad-spectrum antibiotics in preterm infants have been associated with necrotizing enterocolitis (NEC), but the exact mechanisms that explain this association remain poorly defined.
  
  
  Objective: To examine the impact of peripartum antibiotics on gut microbiota and intestinal inflammation in the developing gut.
  
  
  Design/Methods: C57BL6 dams were administered broad spectrum antibiotics mixed with sterile drinking water from E15 to postnatal day (P)14 (Fig 1). Gut microbiota were analyzed by targeted 16S PCR for total bacterial density and relative abundance of major bacterial phyla. Effects of antibiotics on inflammatory TLR-signaling and injury in the neonatal gut were evaluated with PCR and histology.
  
  
  Results: Peripartum antibiotics reduced gut bacterial density (Fig 2A) and diversity (Fig 2B) of treated dams compared to untreated controls. Decreased gut bacterial density was also evident among pups of antibiotic-treated dams starting at P8 and persisting to P21 (Fig 2C). Investigation of TLR signaling by PCR showed that at P8, pups of antibiotic-treated dams have significant upregulation of TLR4 signaling (TLR4, IRAK1) and inflammatory cytokines (KC, ICAM1) in the gut compared to pups of untreated controls (Fig 3A). Increased gut TLR4 inflammatory signaling persisted to P21 despite discontinuation of antibiotics by P14 (Fig 3B). Histologic evaluation of terminal ileum revealed that antibiotics alone were insufficient to elicit intestinal injury consistent with NEC (Fig 4).
  
  Conclusion(s): Antibiotic exposure during the early critical period after birth induces gut dysbiosis and negatively impacts the developing gut towards a pro-inflammatory state. These results support ongoing efforts of antibiotic stewardship to avoid routine antibiotics in preterm infants without risk factors for sepsis. Future experimentation is ongoing to assess the effects of shorter antibiotic duration and addition of noxious stimuli on TLR signaling and other markers of intestinal injury.

  Presented at the 2021 PAS Virtual Conference

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  Physicians’ Burnout: A First Step to Development of a Wellness Curriculum

  Tyler Smith, Katherine E. Mason, David D. Williams, and Kadriye O. Lewis

  Background: Prevalence of burnout among physicians is a critical issue impacting all career levels. Identifying burnout begins in medical training with trainees and early career physicians at risk for depression and burnout1. Participation in wellness programs may mitigate burnout perhaps during the COVID-19 pandemic. Online physician wellness activities i.e., coaching and training are offered at a free-standing children’s hospital in the Midwest USA. These programs are well received, but there is no specific curriculum addressing physicians’ wellness needs within the Division of General Academic Pediatrics (GAP). In designing a meaningful program, we conducted a needs assessment survey to gauge GAP physicians’ current involvement in wellness activities and participation challenges.
  
  
  Objective: To determine a framework and core curriculum leading to the development and implementation of an impactful wellness curriculum for GAP physicians.
  
  
  Design/Methods: This survey study used a discrepancy-based needs assessment approach to obtain data from GAP physicians at Children’s Mercy Kansas City (CMHK) about their wellness activities. We developed a survey with sections about wellness activities (7 items) and demographic information (6 items). We piloted the survey with 16 academic pediatricians outside the Division to assess the items’ clarity. The survey was put on REDCap and sent to GAP physicians with 6 reminders sent between July-October 2020. Descriptive statistics: frequencies, percentages, means and standard deviations were used to analyze the data. We obtained Institutional Review Board approval from CMHK.
  
  
  Results: Of 46 GAP physicians surveyed, 24 (52%) completed the survey. Twenty-one (87.5%) physicians participated in weekly wellness activities with 13 (54%) participating more than three times weekly. Barriers to participation included time (96%), clinical duties (91%) and personal responsibilities (81%). GAP physicians preferred wellness activities such as mindful thinking (81%), meditation breaks (70%), microlearning with mobile devices (68%) and mid-day fitness activities (65%).
  
  Conclusion(s): Our study results provided useful information about desired wellness activities and potential barriers that may affect GAP physicians. We plan to use these findings when designing wellness curriculum in the context of instructional design and content selections.

  Presented at the 2021 PAS Virtual Conference

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  Prenatal diagnosis of an uncommon form of a hypoplastic left heart syndrome variant.

  Anmol Goyal, Kelsey Pinnick, Rita France, and Maria Kiaffas

  Background: Mitral valve dysplasia syndrome (MVDS) is a rare form of congenital heart disease, similar to hypoplastic left heart syndrome (HLHS). Prenatal identification is important for counseling, delivery planning and postnatal management.

  Case: A 39 year-old woman underwent fetal echocardiography at ~34 weeks gestation for evaluation of fetal cardiomegaly and hydrops revealing: biatrial enlargement, mild-to-moderate mitral and tricuspid valve insufficiency, echobright mitral valve apparatus, biventricular dilation, severe LV fibroelastosis (EFE) and systolic dysfunction, mild hypoplasia of aortic valve annulus and aortic arch, and a thick restrictive atrial septum (RAS) with left to right flow (Fig 1a-c).

  Decision‐making: Although critical aortic stenosis was considered initially, MVDS seemed more likely given above characteristic findings. Delivery planning included elective C-section with standby catheterization laboratory and ECMO teams, given RAS and cardiac dysfunction. Patient was listed for transplant as biventricular or single ventricle repair were deemed unfeasible, given valvar insufficiency, LV dysfunction and EFE (Fig 1d-g).

  Conclusion: MVDS is uncommon but should be considered with HLHS differential, in presence of a normal-dilated left atrium and ventricle, LV dysfunction and EFE, RAS and aortic valve and arch hypoplasia. Planned delivery and immediate postnatal atrial septostomy is warranted and cardiac transplantation is often the only therapeutic option.

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  Prevalence of Mycoplasma genitalium and Macrolide Resistance in Adolescent Females Receiving Care at a Pediatric Hospital

  Kayla Barnes, Bishnu Adhikari, Rangaraj Selvarangan, Christopher J. Harrison, and Melissa K. Miller

  Background: Mycoplasma genitalium is an established sexually transmitted cause of nongonococcal urethritis in males and macrolide resistance is increasing. The pathogenic role is less well-defined in adolescent females and guidelines recommend M. genitalium testing only be considered in cases of persistent or recurrent cervicitis and pelvic inflammatory disease (PID). We lack understanding of the prevalence and macrolide resistance of M. genitalium in adolescent females.
  
  
  Objective: To determine the prevalence of M. genitalium and rate of detected macrolide resistance among adolescent females seeking care at a pediatric children’s hospital.
  
  
  Design/Methods: We collected 200 salvaged urogenital samples (56 urine and 144 vaginal) from adolescent females aged 12-17 years seeking care between November 1, 2019 and April 31, 2020. We used Aptima Mycoplama genitalium assay (Hologic) to detect M. genitalium, Lightmix Modular Mycoplasma Macrolide kit (TIB MOLBIOL) to determine macrolide resistance, and confirmed findings by using Sanger Sequencing. We reviewed electronic medical records to determine presenting symptoms, concurrent urinary tract or sexually transmitted infections, demographics, and sexual risk behaviors. To look for associations with presence of M. genitalium, we used t-tests and chi-square or Fisher’s Exact tests.
  
  
  Results: The prevalence of M. genitalium was 9.5% (95% CI, 5.4, 13.6). Of the 19 positive specimens, 5 were urine and 14 were vaginal samples. Macrolide resistance was detected in 89.5% positives (95% CI, 75.7, 100). Both susceptible positives were from vaginal specimens. Among these positives, 89.5% had history of positive/negative sexual experience documented and 53% reported history of vaginal intercourse. Compared to those without co-infection, females with any co-infection were more likely to have M. genitalium (6.6% vs. 18.4%, p=0.023). The most common co-infection among positives was Chlamydia trachomatis (26.3%) and nearly all (80%) of these patients received azithromycin. The mean age for females with M. genitalium was somewhat higher than those without (17.1 + 0.7 vs 16.4 + 1.7, p=0.057). Compared to white females, black females were more likely to have M. genitalium (3.3% vs 17.4%, p=0.015%).
  
  Conclusion(s): M. genitalium can often be detected among genitourinary samples from adolescent females and is nearly always resistant to macrolide antibiotics. Further work is needed to clarify the potential pathogenic role of M. genitalium in adolescent female reproductive health.

  Presented at the 2021 PAS Virtual Conference

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  Rates of Positive Suicide Screens among the Emergency, Inpatient and Outpatient Clinics at a Tertiary Care Children’s Hospital

  Fajar Raza, Hung-Wen Yeh, John Lantos, Mark Connelly, and Shayla Sullivant

  Background: Prior research has suggested that rates and acuity of suicidality are elevated among patients seen in EDs and in certain clinics. However, the occurrence and severity of suicide risk has been rarely studied in the pediatric clinic populations due in part to unsystematic screening. We examined suicidality across different pediatric clinical care settings based on data from our newly implemented hospital-wide suicide risk screening program.
  
  
  Objective: To determine a) which patient populations presented with the highest rates of suicidality; and b) the percentage of patients who had current thoughts of suicide and were thus deemed “acute.”
  
  
  Design/Methods: We conducted a retrospective analysis of the clinical data repository. Adolescents were screened for suicide risk between Feb 2019 and Jan 2020. Patients were eligible for suicide risk screening if they were >12 years old and had a medical visit in the inpatient (IP), emergency (ED), urgent care (UC), or outpatient (OP) clinics of a dedicated pediatric hospital in the midwest. We used the 4-question ASQ (Ask Suicide-Screening Questions) by which a positive response to any of the 4 questions was considered a positive screen. Among positives, those who gave a positive response to question 5 (“are you having thoughts of killing yourself right now?”) were classified as “acute risk.”
  
  
  Results: Out of the 101,732 screenings completed during this time, 11,460 (11.3%) were positive, and 734 were at acute suicide risk. Overall positivity rates were highest among inpatients (18.6%), followed by the ED (18.0%), OP clinics (9.5%), and UC (8.8%). The highest rate of acute positives was found in the ED (3.1%), followed by IP (2.0%). The lowest rates of acute risk were observed for UC (0.2%) and OP clinics (0.1%). Among UC clinics, the highest rates of suicidality occurred in the Child Abuse Clinic (40.2%), followed by Adolescent Medicine (24.9%), Sleep and Teen Clinics (both 17.6%). The highest rate of acute suicide risk occurred in the Child Abuse Clinic (1.7%).
  
  Conclusion(s): Suicidality among pediatric patients is highest among adolescents seen in the inpatient unit and those seen in the ED. Some pediatric outpatient clinics also have high rates of suicidality but the rate of acuity appears to be lower in this setting relative to the inpatient and ED setting. Data on the acuity of risk and on the prevalence of acute risk in different clinical settings can be used to plan for allocation of mental health resources to follow-up on positive screens.

  Presented at the 2021 PAS Virtual Conference

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  Recurrent neonatal herpes simplex virus infection associated with IRF7 and UNC93B1 variants

  Venkatesh Sampath, Megan H. Tucker, Heather Menden, Sheng Xia, Wei Yu, and Nikita Raje

  Background: Neonatal herpes simplex virus (HSV) is a devastating disease with high mortality. In adults and children, genetic variants in the toll-like receptor 3 (TLR3) pathway increase susceptibility to herpes simplex encephalitis (HSE), but the genetic basis of susceptibility to neonatal HSV is unknown. We hypothesized that deleterious variants in the TLR3 pathway increased vulnerability to HSE in neonates. We investigated immunogenetic studies in an infant with neonatal skin, eye, mouth (SEM) HSV followed by HSE.
  
  
  Objective: To combine exome sequencing with in vivo and in vitro immune functional analysis to discover the immunogenetic basis of HSV vulnerability in proband.
  
  
  Design/Methods: The proband developed SEM HSV1 on day 7 of life and recovered fully with acyclovir. At 1 year of age he presented with seizures and was diagnosed with HSV1 HSE. Exome sequencing was performed to identify pathogenic genetic variants. An immune work up including peripheral blood monocyte (PBMC) functional TLR assay was done. Wild type and mutated alleles were transfected into THP1 monocyte cell line stably expressing an interferon regulatory factor 3 (IRF3) promoter-driven luciferase reporter. Poly(I:C) (1ug/mL), a TLR3 ligand, was used to stimulate THP1 for 24hr prior to luciferase assay and qRT-PCR for interferon (IFN) α and β gene expression.
  
  
  Results: We identified rare missense mutations in interferon regulatory factor 7 (IRF7) (p.Arg100Pro) and UNC-93 Homolog B1 (UNC93B1) (p.Pro404Ser) genes. Immune work up including CD4, CD8, NK cell, and immunoglobulins was normal, except for a total loss of PBMC cytokine response to TLR3 stimulation (Fig.1). Luciferase assays in THP1 showed dramatically reduced TLR3-driven IRF3 promoter activity in response to poly(I:C) with IRF7 and UNC93B1 variants (Fig. 2 & 3). Similarly, IFNα and IFNβ expression induced by poly(I:C) was enhanced by wild type IRF7 and UNC93B1 alleles, but strongly suppressed by mutant IRF7 and UNC93B1 alleles (Fig. 2 & 3). Combining the 2 mutant alleles compounded disruption of TLR3 signaling (Fig. 4).
  
  Conclusion(s): We identified 2 variants (IRF7, UNC93B1) that disrupted the TLR3-response to HSV in vitro and in vivo in an infant with recurrent HSV. This is the first report of human HSV disease associated with IRF7 mutation. Neonatal HSV may be a phenotype for immunodeficiency in the TLR3 pathway genes. Infants with severe neonatal HSV may warrant genetic screening to identify variants that increase recurrence risk, and prolonged acyclovir prophylaxis should be considered.

  Presented at the 2021 PAS Virtual Conference

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  Registration of newly diagnosed children with autism spectrum disorder and developmental disabilities at state regional offices

  Whitney Rolling and Rachel Goodson

  • In fiscal year 2020, 39,220 Missouri residents utilized developmental disability services through the Missouri Department of Mental Health.1 • Developmental disability services account for 53% of Missouri’s state mental health funding (about 1.3 billion dollars annually).

  • Physicians and psychologists are required for making eligible diagnoses, but registration for state support is patient dependent and can be perceived as an extensive paperwork process.

  • Project Goal: Measure and increase the percentage of eligible patients registered for their state mental health resource offices.

• 

  Response to dexamethasone predicts diagnosis of severe (type 2) bronchopulmonary dysplasia or death

  Christopher R. Nitkin, Keith Feldman, Alain Cuna, Alexandra Oschman, William E. Truog, Michael Norberg, Jane Taylor, and Tamorah Lewis

  Background: Bronchopulmonary dysplasia (BPD) is the most common respiratory morbidity after preterm birth but requires diagnosis at 36 weeks postmenstrual age (PMA). Dexamethasone is often used to treat infants at high-risk of BPD. The ability for earlier prediction of BPD, based on steroid response, could be useful as a surrogate marker for new therapies.
  
  
  Objective: To construct a model that predicts severe BPD or death at 36 weeks PMA based on clinical response to dexamethasone.
  
  
  Design/Methods: Retrospective chart review of preterm infants treated with dexamethasone between 2010-2020 at a Level IV NICU with data collected on demographics, age of steroid initiation, mode and level of ventilatory support during treatment, and pCO2 on day 1, 3, and 7 of steroid use. Highest mode of ventilation was assessed as either high frequency oscillatory ventilation, conventional invasive ventilation, or any form of non-invasive ventilatory support; while support level was represented by respiratory severity score (RSS = MAP*FiO2). BPD outcomes were defined according to the 2017 BPD Collaborative definition. The composite of mild, moderate, or severe (type 1) BPD was used as referent group to assess odds against the composite of severe (type 2) BPD or death.
  
  A regularized logistic model was fitted using the following variables: gestational age, sex, age of steroid initiation, baseline (Day 1) and percent change from baseline (Day 7 vs Day 1) in RSS and pCO2, and ventilator mode change from baseline. The resulting predicted probabilities were divided into quartiles to obtain a discrete risk level (level 1 to 4).
  
  
  Results: 94 infants were treated with dexamethasone prior to 36-week BPD assessment. A 10,000-iteration bootstrap was performed, and a risk score was predicted for infants not included in the resampled data at each iteration. The proportion of those with severe (type 2) BPD or death at each risk level were evaluated (Figure). For comparison, predictions were also made with a baseline model using only demographic data. Increasing risk category was well aligned with rising outcome incidence, increasing from ~20% of infants at level 1 to just over 55% of infants at level 4.
  
  Conclusion(s): The addition of changes in ventilatory parameters with dexamethasone improved BPD prediction compared to baseline demographics alone. Incorporating drug response phenotype into a BPD model may enable more rapid development of future therapeutics.

  Presented at the 2021 PAS Virtual Conference

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  Simulation Based Clinical Systems Testing in the Pediatric Emergency Department to Prepare for COVID-19 Pandemic

  Christopher S. Kennedy, Marc Sycip, Lisa Ell, and Shautonja Woods

  Background: The COVID-19 prompted pediatric emergency departments (PED) to prepare for a surge in patients. In response, guidelines developed represent “work as imagined” and may not reflect work as done. In situ simulations could identify gaps and help to mitigate errors. Simulation-based clinical systems tests (SbCSTs) can detect latent safety threats (LSTs) in systems design.
  
  
  Objective: Our aim was to use SbCSTs combined with rapid cycle training to test hospital system modifications for ED preparation. This method represenst a new application of SbCSTs. The research questions were in 2 frames: 1. Can rapidly deployed SbCSTs identify LSTs and recommendations for improvement and 2. Do providers consider rapid SbCSTs a way to improve preparedness?
  
  
  Design/Methods: The study took place in a PED and was approved by the IRB as non-human subject research. SbCST scenarios tested guidelines/job aids, equipment, and ways to mitigate exposure. Each case used “tipping-point”(s) to test workflow. Short scripted debriefs reviewed guidelines, staff input, and the simulation repeated. Participants evaluated the SbCST with a survey. Three sim staff collected observations on a standardized form for which process was tested, staff response, and LSTs identified.
  
  
  Results: Question 1. LST identification: From the 44 simulations, 64 staff identified 103 unique LSTs. LSTs were categorized as follows: Job Aids/tasks 37 (36%), Isolation Measures (PPE) 30 (29%), Communication/personnel: 18 (17.5%), and Equipment 18 (17.5%). Common LSTs identified: In the Job Aid category: simplify intubation job aid, Isolation Measures: staff had concerns about PPE changes prior to generating aerosol, Equipment: adjust equipment needs to avoid delays, and change PPE, and Communication/Personnel: minimizing staff during resuscitations. Question 2. Staff evaluations (strongly agree, (SA) to strongly disagree, (SD)): Worth the time it took: 86% SA, 14% some what agreed (SWA). An acceptable way to improve: 92 % SA, 8% SWA. An effective way to test: 92% SA, 8% SWA. Debriefing allowed staff to share ideas: 86% SA SWA 8%, and Average 6%.
  
  Conclusion(s): This study showed that SbCST methods are adaptable for preparedness evaluation and training. Participant evaluations reveal a high regard for this method for practicing/improving the COVID-19 process. This work highlights a new application of SbCSTs that could increase system preparedness and reduce errors.

  Presented at the 2021 PAS Virtual Conference

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  Simulation Based Clinical Systems Testing of a Pediatric ED to Improve Staff and Process Readiness for Pediatric Hypoglycemia

  Kevin Meilak MD and Christopher S. Kennedy

  Background: Hypoglycemia is the most common metabolic disorder in children in pediatric emergency department (ED) settings 1. Children may present with nonspecific symptoms, or asymptomatically2. So identification/treatment is very challenging. Delayed recognition and under treatment can lead to poor patient outcomes including seizure, coma, and death. Simulation-based clinical systems tests (SbCSTs) are useful to detect gaps/latent safety threats (LSTs) in system design.3-5
  
  
  Objective: Our aim was to use SbCSTs combined with rapid cycle training to test system function for ED treatment of hypoglycemia.3-5. The research questions were in 2 frames: 1. Can SbCSTs identify gaps/LSTs and recommendations for improvement and 2. Would providers consider SbCSTs acceptable way to improve?
  
  
  Design/Methods: The study took place in a children’s hospital ED and was approved by the IRB as non-human subject research. We conducted SbCSTs with staff responding to a 5-month old with hypoglycemia and used “tipping-point”(s) in care to emulate challenges and a Gamaurd mannequin and a tablet-based “monitor”(SimMon). Short scripted debriefs reviewed guidelines, staff input, and then staff repeated the simulation. Participants used a survey to evaluate the SbCSTs. Two sim staff observed, and took notes on a standardized reporting form and included staff response, any gaps/LSTs identified.
  
  
  Results: Preliminary results: 12 SbCSTs were conducted with 22 staff, 13 (59%)(7- MDs, 4-RNs, 2-APRN) filled out anevaluation. For question 1 LST identification: Staff identified 50 LSTs. Each LST was categorized for cause as follows:14 (28%) glucose gel location/administration concern, 12 (24%) need for a better job aid, 10 (20%) were related to dextrose dosing errors, 7 (14%) POC glucose recheck timing, and 7 (14%) inappropriate treatment. For question 2: An acceptable process: (strongly disagree, SD to strongly agree, SA): Worth the time it took: 85% SA, 15% somewhat agreed (SWA). Improved staff readiness: 85 % SA, 15% SWA. An effective way to test/provide solutions: 85% SA,15% SWA. The debrief allowed staff to share ideas: 85% SA, 15% SWA.
  
  Conclusion(s): This study demonstrated that simulation-based clinical systems testing (SbCST) methods are adaptable for use in a children’s hospital ED for preparedness evaluation and training. Participant evaluations demonstrate a high regard for this method. The process detected many LSTs but further data analysis with a formal FMEA process will be performed.

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  Spanish-speaking families’ perspectives on the acceptability and impact of culture and language coaching for bilingual residents

  Ryan Northup, Francisco Martinez, and Jeffrey D. Colvin

  Background: Culture and language coaching in the CHiCoS (Clínica Hispana de Cuidados de Salud) Program provides bilingual (English-Spanish) residents with longitudinal, personalized training in health care Spanish and cultural aspects of care. This intensive 1:1 training by a culture and language coach (CLC) over three years has been shown to improve residents’ skills and family satisfaction with care. Families’ perspectives on acceptability of the presence and impact of the CLC during visits have not been formally described.
  
  
  Objective:
  
  
  Design/Methods: In this descriptive, cross-sectional pilot study, we surveyed Spanish-speaking caregivers who received care from any of 18 bilingual CHiCoS residents accompanied by a CLC in our academic pediatric primary care clinic. The 10-question survey was created by the study team in Spanish using a formal process including piloting and revision. Respondents surveyed by telephone after their visit were asked how well the resident spoke and understood Spanish, effectiveness of communication, how the CLC impacted communication, future preference for coached vs interpreted visits, and overall satisfaction.
  
  
  Results: Sixty of 67 recruited parents (90%) completed the survey. A majority reported that their resident spoke (65%) and understood (63%) Spanish very well, with little or no intervention needed from the CLC. The remainder felt that the resident spoke well but needed occasional support from the CLC to achieve complete communication. None had major difficulty understanding their resident. Overall communication was either “very easy and direct without problems” (57%) or “more or less easy,” with problems being “quickly resolved” (43%). Most felt that the CLC improved communication “a lot” (77%) or “somewhat” (10%). For a hypothetical future visit, 58% preferred a coached visit with a doctor speaking at least some Spanish to an interpreted visit with a doctor speaking no Spanish; the remainder said either option would be equally good. None preferred an interpreted visit. All respondents were either “very satisfied” (83%) or “satisfied” (17%) with the care given by the resident-CLC team.
  
  Conclusion(s): Spanish-speaking caregivers strongly support culture and language coaching for bilingual pediatric residents and described positive impact on in-visit communication. Despite the majority of CHiCoS residents not yet passing their validated language proficiency exams, all families reported complete communication and satisfaction with their visits.

  Presented at the 2021 PAS Virtual Conference

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  Teaching Pediatric Procedural Pain and Anxiety Management to Residents: Early Outcomes of a Newly Developed Curriculum

  Jennifer J. Dilts, Brian R. Lee, Shobhit Jain, Ross Newman, Sarah Fouquet, Michael Brancato, and Kadriye O. Lewis

  Background: Poorly managed pediatric pain has negative long-term outcomes, including needle phobia, increased pain and anxiety with subsequent procedures, and healthcare avoidance in adulthood. Evidence-based interventions to reduce procedural pain and anxiety are vastly underutilized, and a literature search revealed no specific curriculum to teach residents optimal skills for pain and anxiety management in minor procedures (e.g. venipuncture, laceration repair). Thus, we developed a multimedia-based lecture with PowerPoint, utilizing results from a focus group interview (conducted with 7 pediatric residents, to determine educational content and identify residents’ needs and learning preferences).
  
  
  Objective: To measure residents’ learning outcomes (knowledge, attitudes, perceived competence, and practice change) and satisfaction with a newly developed procedural pain and anxiety curriculum.
  
  
  Design/Methods: Pediatric and combined internal medicine/pediatric residents were invited to complete the curriculum online through the in-house learning management system (Cornerstone) during their emergency medicine rotation. Data were collected between July 2019 and June 2020 (pre- and post-tests, as well as a follow-up survey 3-12 months later). McNemar’s test was used to measure pre- and post-test knowledge gains while Wilcoxon signed-rank test was used to compare changes in attitudes, perceived competence, and reported changes in procedural management.
  
  
  Results: Seventy-two residents were invited to participate, with 28 completing the intervention with pre- and post-tests (39% completion rate) and 12 of those residents completing the follow-up survey. Residents increased their knowledge by 24.3% (p<0.0001) (Figure 1). There was no significant change in attitudes towards pain and anxiety management. Positive improvements, although non-significant, were seen in perceived competence and reported change in medical practice (Figures 2 and 3). Course evaluation data found that 75% of residents planned to utilize knowledge from the course in the next few weeks (Table). The majority of residents who completed the follow-up survey reported that knowledge learned in the course improved their practice and/or led to changes in their practice.
  
  Conclusion(s): Early outcomes of the curriculum revealed significant knowledge increase. Additionally, these results provide a foundation for evaluation of an online game-based version of the curriculum, which we plan to make available to learners beyond our home institution.

  Presented at the 2021 PAS Virtual Conference

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  Using Standardized Scripting to Improve Antibiotic Stewardship in a National Pediatric Urgent Care Collaborative

  Amanda Nedved, Melody Fung, Cindy Liu, Rana Hamdy, and Amanda Montalbano

  Background: A study using administrative data reported urgent care providers as having the highest rates of inappropriate antibiotic use for upper respiratory illnesses. In a national survey, pediatric urgent care providers reported family expectations as a primary driver for prescribing inappropriate antibiotics. Standardized scripting has been effective at reducing unnecessary antibiotics while increasing family satisfaction.
  
  
  Objective: To reduce inappropriate prescribing for upper respiratory infections (acute otitis media (AOM), otitis media with effusion (OME), and pharyngitis) in pediatric urgent cares by 20% by December 1, 2020 through use of standardized scripting in Year 2 of a national pediatric urgent care quality improvement collaborative.
  
  
  Design/Methods: Participants were recruited via email, newsletters, and webinars from pediatric urgent care national societies. Each site committed at least 3 providers who each submitted data from 10 encounters per month. Antibiotic prescribing was defined as appropriate based on consensus guidelines. Previously published antibiotic stewardship scripting for viral upper respiratory infections was adapted for use with the three target diagnoses. Patient and family advisors reviewed all scripting and their feedback was incorporated into the revised standardized scripting. Clinical examples for each diagnosis using the standardized scripting were provided to the collaborative by use of digital cartoon videos, written framework, and templated discharge instructions. Data from clinical encounters were submitted via a REDCap form, analyzed for inappropriateness, and reported back to participating sites via run charts during monthly webinars.
  
  
  Results: The 104 participants from 10 institutions submitted 1,150 encounters for analysis in the intervention cycles (May-December 2020). Overall inappropriate antibiotics decreased from 26.4% to 16.6% (p=0.13). Inappropriate antibiotic use decreased in AOM (38.6% to 26.5%; p=0.12) and pharyngitis (14.5% to 8.8%; p=0.26). OME increased from 30.8% to 46.7% (p=0.18) (Figure 1). During the study immediate antibiotic prescriptions for OME decreased; however, delayed prescribing increased (Figure 2).
  
  Conclusion(s): In its second year, this national collaborative developed standardized scripting to overcome the barrier of perceived family expectations to decreases inappropriate antibiotic prescriptions in pediatric urgent care for AOM and pharyngitis. Future interventions will target the inappropriate use of delayed prescribing in OME.

  Presented at the 2021 PAS Virtual Conference

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  Utilization of Enteral Tranexamic Acid To Stabilize Gastrointestinal Hemorrhage in Pediatric Patients on ECMO

  Gina Patel, Jenna Miller, Thomas M. Attard, and Asdis Finnsdottir Wagner

  Hemorrhagic and thrombotic complications on Extracorporeal Membrane Oxygenation (ECMO) support are associated with significant morbidity and mortality. There is a paucity of literature describing the incidence and management of Gastrointestinal (GI) bleeding on ECMO. We describe the use of enteral tranexamic acid (TXA) as an alternative strategy in two pediatric patients with GI hemorrhage on ECMO. Case 1 A 5-year-old with Wilms Tumor required Veno-Venous ECMO due to respiratory failure associated with pulmonary hemorrhage and air-leak syndrome. Her course was complicated by severe GI hemorrhage refractory to IV proton pump inhibitor (PPI), IV TXA and octreotide infusions. Concomitant IV TXA and cessation of systemic anticoagulation coincided with emergent transition to Veno-Arterial (VA) ECMO after cannula thrombosis. Procedural interventions included esophagogastroduodenoscopies (EGD) revealing gastric ulcers, two endovascular embolization procedures, and a third arteriogram due to continued bleeding that did not identify a source. Enteral TXA (20 mg/kg q 8 hours) was then begun with resolution of GI bleeding, reduction in blood product transfusion and no further emergency circuit changes. She survived to hospital discharge. Case 2 A 3-year-old with a burn injury required VA ECMO due to cardiopulmonary collapse. Her course was complicated by GI hemorrhage. She received a PPI, octreotide infusion and was started on IV and enteral TXA (10 mg/kg q 8 hours). An EGD did not identify a bleeding source. There was no interruption in circuit anticoagulation or integrity. She remained on enteral TXA for 48 hours until GI bleeding resolved. She survived to ECMO decannulation. Patients supported by ECMO require systemic anticoagulation thus making GI bleeding difficult to manage. We report the use of enteral TXA to provide anti-fibrinolysis. This was associated with cessation of bleeding but not associated with further circuit thrombosis. Enteral TXA can be an additional tool used for GI bleeding on ECMO.