These slides have been presented at a meetings in Children's Mercy and around the world. They represent research that was done at the time they were created, and may not represent medical knowledge or practice as it exists at the time viewers access these slide presentations.>
Leadership Across the Career Continuum: Using Self-Reflection Effective Leadership Practices for Optimal Team Functioning
Emily Bonanni, Grant M. Latta, Michael Platt, Christine Irvin, Angela Etzenhouser, Megan Collins, Sian Best, Jonathan Ermer, Joy L. Solano, and Jacqueline M. Walker
Have you ever found yourself in a formal or informal leadership role and felt underprepared because of a lack of formal leadership training? Have you noticed unused potential in those around you and wondered how you maximize it? As academic pediatricians, we are identified as leaders by patients and their families, trainees of all levels, members of our multi-disciplinary care teams, and our peers. We are a group of passionate clinician educators who have found ourselves in both formal and informal leadership roles and have found success in these roles with leadership training. Our interactive workshop will give you the tools necessary to lead trainees and colleagues successfully through challenging situations by introducing you to renowned leadership paradigms and helping you to apply these techniques to your roles through self-reflection. We intend to teach this in a way that keeps you mindful of well-intentioned missteps in which we accidentally undermine the intelligence and talents of those around us. After we identify these common subversive actions, we will apply leadership frameworks to overcome them so we can maximize our teams' potential and success.
Nelimar Cruz-Centeno, James A. Fraser MD, Shai Stewart MD, Derek Marlor, Rebecca M. Rentea, Pablo Aguayo, David Juang, Richard J. Hendrickson, Charles L. Snyder, Shawn D. St.Peter, Jason D. Fraser, and Tolulope A. Oyetunji
Introduction: Initial management of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Here we describe the protocol and subsequent outcomes. Methods: We conducted a single-center retrospective review of patients diagnosed with HPS from 2016-2020. All patients were managed per the protocol outlined in Figure 1. All were given formula or breast milk after the post-anesthesia care unit and discharged home after tolerating three consecutive feeds. Feedings were given every 2-3 hours even if emesis occurred. Full feeds were defined as 60 ml of full-strength formula or breast milk every 2–3 hours ad lib. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the total number of preoperative labs drawn, time from arrival to the hospital to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate. Results: There were 271 patients included. The majority of the patients were male (83%, n=225) and Caucasian (77.5%, n=210). The median age and weight were 5 weeks (IQR 3.9,6.5) and 3.9 kg (IQR 3.4,4.4), respectively. None of the patients required a nasogastric tube or arterial blood gas sample. A total of 117 patients (43.2%) had electrolytic disturbances that required fluid boluses in addition to (1.5 x) maintenance fluids before surgical intervention. The median number of lab draws was 2 (IQR 1,2), with a median time from arrival to surgery of 19.2 hours (IQR 15.1,24.9). The median time from surgery to first feed and full feeds was 1.9 hours (IQR 1.2,2.7) and 11.4 hours (IQR 6.2,19.1), respectively. Patients had a median postoperative LOS of 22.2 hours (IQR 9.6,30.6). Re-admission rate within the first 30 postoperative days was 3.3% (9/271), with 2.2% (n=6) of re-admissions occurring within 72 hours of discharge. Indications for re-admission included stridor (1), decreased oral intake (1), and vomiting (7). One patient (0.4%) required re-operation due to incomplete pyloromyotomy. Conclusion: This protocol is a valuable tool for perioperative and postoperative management of all patients with HPS while minimizing uncomfortable interventions.
Parent satisfaction with same day discharge after laparoscopic appendectomy for non perforated appendicitis
Nelimar Cruz-Centeno, James Fraser, Shai Stewart MD, Derek Marlor, Rebecca M. Rentea, Pablo Aguayo, David Juang, Richard J. Hendrickson, Charles L. Snyder, Bhargava Mullapudi, Shawn D. St.Peter, Jason D. Fraser, and Tolulope A. Oyetunji
Background: Same-day discharge (SDD) after laparoscopic appendectomy for acute non-perforated appendicitis is safe, without an increased rate of postoperative complications, emergency department visits, or re-admissions. We aimed to evaluate caregiver satisfaction with this protocol. Materials and Methods: Patients discharged on the day of laparoscopic appendectomy for non-perforated acute appendicitis were identified between January 2022-August 2022. Surveys to evaluate satisfaction with the protocol were distributed to the caregivers via e-mail or text message 96 hours after discharge. Telephone surveys were conducted if there were no responses to the initial online survey. The surveys assessed comfort with SDD, post-operative pain control adequacy, post-operative provider contact, and overall satisfaction. The protocol focused on avoidance of narcotics in the postoperative period and immediate return to a regular diet. Results: A total of 255 cases of non-perforated acute appendicitis underwent SDD. The survey response rate was 50.6% (n=129). Most respondents were Caucasian (69.0%, n=89) and male (51.9%, n=67), with a median age of 12.0 years (IQR 8.9,14.7). The median postoperative length of hospital stay was 3.8 hours (IQR 3.2,4.8). The overall satisfaction rate was 91.5%, with 118 caregivers feeling satisfied with SDD. Most caregivers felt comfortable with the SDD protocol (89.9%, n=116), with 22.5% (n=29) calling a medical provider postoperatively. Approximately nine out of ten caregivers reported that pain was adequately controlled (91.5%, n=118). In contrast, those that were dissatisfied reported issues with pain control and anxiety with SDD after a surgical procedure. Conclusions: Caregiver satisfaction and comfort with same-day discharge following laparoscopic appendectomy is high with appropriate anticipatory guidance and preoperative education.
Introduction/Hypothesis Young children with scald burns experience severe complications compared to older children. A paucity of data exists to support these observations. This study compares clinical features and complications of younger versus older pediatric patients with scald burns at four children’s hospitals participating in the Pediatric Injury Quality Improvement Collaborative (PIQIC). This collaborative includes five pediatric burn centers that utilize research to improve quality of burn care. 485 Methods This is a retrospective cohort study of scald burn patients admitted from 2010 to 2020 to four pediatric hospitals participating in PIQIC. Patients with total body surface area (TBSA) < 15% were excluded. Patients were categorized by age into three groups: toddlers (0–3 years), children (3-10 years), and adolescents (>10 years). The adolescent group was excluded with three patients in this group. Demographics, clinical features and adverse events were compared between age groups. For categorical variables, counts and percentages are reported; P-values were determined by Fisher’s Exact test. Continuous variables are reported using median and inter-quartile range; P-values were determined using the Wilcoxon Rank Sum test. Results Ninety-five patients were identified; 73 (76%) were in the toddler group. Although median burn size was larger in children (24 [21-36] vs 21 [18-30] % TBSA, p<0.001), toddlers had longer median intensive care unit (ICU) LOS (3 [2-16] vs 3 [2-9], p<0.001) and more median mechanical ventilator (MV) days (13 [1-137] vs 5 [2-138], p<0.001) than the child group. There was notable incidence of sepsis, nosocomial infection and abdominal catastrophe in the toddler group. Abdominal catastrophes only occurred in the toddler group, with 5 patients (7%) affected. Mortality was only observed in the child group (n=2, 9%). Conclusions Scald burns are more prevalent in the toddler group compared to the child group. Mortality risk may not be higher in this group, but they encounter longer ICU LOS, higher MV days, and incidence of sepsis, nosocomial infection, and abdominal catastrophe. This is one of the largest reports of abdominal catastrophe in this patient population to our knowledge. Continued investigation will help better understand this patient population.
Background: The assessment of pain in children with severe neurologic impairment (SNI) can be more challenging than in neurotypical children.
Objective: To describe the type, number of classes, and duration of post-operative pain medications for procedures common among children with SNI. Secondarily, to describe the variability in pain management strategies across children’s hospitals, specifically for opioid administration.
Design/Methods: This retrospective cohort study of the Pediatric Health Information System included children hospitalized with SNI aged 0-21 years old who underwent common procedures during 2019. We defined SNI using previously described high-intensity neurologic impairment (HINI) diagnosis codes and identified six common (>500 encounters) procedures among our population (e.g., fracture treatment, tracheostomy, spinal fusion, ventriculoperitoneal shunt placement (VP shunt), colostomy, or heart valve repair) using the clinical classifications software (CCS). Clinical and demographic information were summarized using bivariate statistics. Children excluded from this cohort did not undergo any of the six preselected procedures, had multiple procedures performed, or received an organ transplant. Medication classes were defined using the Classification of Palliative Care Pain Medications. Non-opioid medications were excluded from analysis to hone in on opioid administration.
Results: The cohort consisted of 7180 children; 65.9% had 1 HINI diagnosis, and 12.0% had 3+ HINI diagnoses. The proportion of post-operative days with pain medications ranged from the least 28.8% (VP shunt) to the most 71.7% (spinal fusion). The number of classes of pain medications ranged from the least 0-1 (VP shunt) to the most 2-4 (Tracheostomy, Table 2). We observed notable variability in the use of opioids across hospitals (0% to 100% overall, p<.001) and by procedure (Colostomies, Heart Valve Repair, Tracheostomies and VP Shunts at 0% to 100% for Spinal Fusion, Figure 1).
Conclusion: Children with SNI experienced variability in the type, number of classes, and duration of all pain medications delivered post-operatively. This included an inconsistent use of opioids based upon hospital and procedure. Our findings indicate the need for both a standardized approach to the assessment of pain and post-operative pain management for children with SNI.
Pediatric In-Hospital Cardiac Arrests: We Have More to Learn About Patient Demographics and Outcomes
Nathan LaVoy, John Cowden, Jenna Miller, Asdis Finnsdottir Wagner, Shekinah Hensley, and Stephen Pfeiffer
Introduction: Prior pediatric studies show an association between patient demographics and mortality after in-hospital cardiac arrests (IHCA). To our knowledge, this has not been assessed in pediatric intensive care units (PICU). This study aims to evaluate the impact of demographics and code characteristics on outcomes after IHCA in a quaternary referral PICU. Methods: A single center retrospective review of PICU IHCA events from 2010-2021 was performed. Patient demographics included age, gender, race/ethnicity, and language. Primary diagnosis was defined as cardiac or non-cardiac. The use of ECMO, CRRT, or defibrillation were included as code characteristics. The primary outcome was survival to hospital discharge. Adjusted odds of mortality (aOR) were obtained using PRISM III scores to adjust for illness severity. Data obtained via Virtual Pediatric System© and chart review. Results: 377 patients (median age 11 months) had 520 PICU IHCA events. 59.4% identified as White, 16.2% Black, 8.3% Hispanic, and 1.5% Asian. Overall survival was 49%. Adjusting for disease severity, there was no difference in survival rates between females (43.3%) vs. males (54%) [aOR 1.26(p=0.278)] or racial/ethnic groups: Hispanic 39.5% [aOR 1.75(p=0.214)], Asian 25.0% [aOR 4.74(p=0.063)], Black 51.2% [aOR 1.13(p=0.664) vs. White 51.1%. Language had no impact on survival: Spanish 36.8% vs. English 49.3% [aOR 1.08(p=0.912)]. Cardiac diagnosis survival was 54.5% vs. non-cardiac 42.2% [aOR 0.75(p=0.166)]. Although different, survival rates were not statistically significant in patients requiring ECMO (Black 33.3% [OR 1.70(p=0.485), Asian 0% [OR 1.99(p=0.302)] vs. White 45.9%), CRRT (Hispanic 20% [OR 1.49(p=0.999)], Asian 0% [OR: 1.34(p=0.819)] vs. White 27.3%), or defibrillation (Asian 0% vs. White 39.1% [OR 0.60(p=0.999)]). Conclusion: Controlling for illness severity, there were no statistically significant outcome differences based on demographics after IHCA in the PICU. This is inconsistent with previously published data on outcomes following IHCA. While this single center study did not assess CPR performance or post-arrest care, it provides framework for future analysis of IHCA in the PICU and identifying risk factors for mortality in this specific patient population.
Derek Marlor, Kayla B. Briggs, Shai Stewart MD, Nelimar Cruz-Centeno, Charlene Dekonenko, Tolulope A. Oyetunji, and Jason D. Fraser
Introduction: Our institution previously reported on outcomes of children with untreated and not spontaneously draining breast abscesses. This study aimed to evaluate the outcomes of all patients with breast abscesses who were evaluated at our institution. Methods: Following IRB approval, all patients < 18-years-old with breast abscesses were included. A total of 145 patients treated from January 2008-December 2018 were identified. Patients were divided into 2 groups; Group 1 included patients initially evaluated at our institution and Group 2 included patients who were initially evaluated at referring centers. The primary outcome was disease persistence. Secondary outcomes were antibiotic utilization, number and type of procedures performed, and risk factors for recurrence. Statistical analysis was performed using STATA® 17 with a p-value of <0.05 indicating significance. Results: A total of 145 patients were identified: 111 (76.6%) in Group 1 and 34 (23.4%) in Group 2. Demographics were similar between groups. Of the 111 patients in Group 1, 2 (1.8%)) were treated with observation alone, 58 (52.3%) were treated with antibiotics alone, 26 (23.4%) were treated with aspiration, and 25 (22.5%) were treated with incision and drainage. Of the 34 patients in Group 2, 4 (11.8%) were treated initially with observation, 22 (64.7%) with antibiotics alone, 5 (14.7%) with manual expression, 2 (5.9%) with incision and drainage, and 1 (2.9%) with warm compresses. Patients in Group 1 were more likely to receive needle aspiration (23.4% vs. 0%; p<0.001) or incision and drainage (22.5.% vs. 5.9%; p<0.001) as initial treatment. Compared to Group 2, patients in Group 1 were more likely to be prescribed clindamycin when treated with antibiotics alone (69.9% vs 18.2%; p<0.001). They also had a 12.6% persistent disease rate (n=14). Second treatment in those with persistent disease included aspiration in 50% (n=7), incision and drainage 45.5% (n=5), antibiotics 7.1% (n=1), and manual expression 7.1% (n=1). No patients had persistent disease following second treatment. Patients in Group 2 were more likely to be treated with antibiotics alone (64.7% vs. 52.3%; p<0.001), with trimethoprim/sulfamethoxazole being the most commonly prescribed antibiotic (54.6%). In patients with persistent disease treated at our institution following initial evaluation at a referring center, 50.0% were treated with antibiotics alone, 26.5% with aspiration, 17.7% with incision and drainage, and 5.9% with manual expression. Following treatment at our institution, the rate of persistent disease was similar between groups (12.6% vs 11.8%;). Conclusions: Persistent breast abscesses may be treated with antibiotics alone in community and tertiary care centers. Disease persistence is similar regardless of the initial treatment setting.
Anik Patel, Pauline Kamau, Ashley Combs, Justus Simba, and Megan Song McHenry
90 million Americans have low health literacy1.in Missouri 35% of adults have prose literacy at or below basic skill level2. Literacy, more specifically health literacy, is a modifiable social determinant of health that has a large impact on patient care and outcome. Poor health literacy in adults is associated with a higher number of ED visits and worse health outcomes3,4. Teach back is a method used in multiple pediatric and adult settings, shown to improve patient outcomes and comfort with discharge instructions5. There is limited data regarding teach back in non-English speaking patients and its efficacy with this group of patients. Our long-term goal is to address disparity in discharge education for non-English speaking patients in the Emergency Department with the use of the teach back method. Our central hypothesis is that using the “Teach Back” method with non-English speaking patients will improve patient medication compliance, and reduce return to ED. To test our central hypothesis and attain the overall objective, we will pursue the following specific aims: Aim 1. Use teach back with non-English speaking patients for discharge instructions. Our working hypothesis is that using teach back for non-English speaking patients will improve patient understanding of discharge instructions and reduce ED return times. We will complete surveys post-discharge with families via phone Aim 2. Measure patient compliance with medications after discharge. Our central hypothesis is that using teach back in the ED setting at discharge will improve patient medication compliance.
Megan Collins, Matt Hall, P J. Chung, Jessica L. Markham, Jessica L. Bettenhausen, L M. Plencer, Molly Krager, Kathyrn Kyler, D Bard, Kayla R. Heller, Roxana Guggenmous, Jordan Keys, and Henry T. Puls
Background: Adverse childhood experiences (ACEs) have been shown to be associated with poor health outcomes, and children living in poverty are more likely to experience ACEs. Our objective was to estimate the association between spending on benefit programs and cumulative exposure to ACEs among children. Methods: This cross-sectional study examined state and federal spending, at the state-level, on 5 categories of public benefit programs: cash, housing, and in-kind assistance; housing infrastructure; childcare assistance; refundable Earned Income Tax Credit; and Medical Assistance Programs (e.g., Medicaid). The primary exposure was median annual spending per person living below the federal poverty limit across 2010-2017 Federal fiscal years (i.e., one observation per state). The primary outcome was state-level percentage of children aged <18 years having ever been exposed to>≥ 4 ACEs, as reported in 2016-2017 National Survey of Children’s Health. Pearson correlations estimated unadjusted correlations. Linear regression models estimated associations after adjustment for states’ racial and ethnic demographics. A sub-analysis including only children 0-8 years of age was conducted to more closely focus on children who could have been first exposed to ACEs in the 2010-2017 Federal fiscal years. Results: Among the 51 states, a median of 6.3% of children (IQR: 5.2, 7.6) had exposure to ≥4 ACEs. Spending varied between states and was correlated with the percent of children with ≥ 4 ACEs (r= -0.41 [95% CI: -0.62, -0.15, p= 0.003]; Figure 1). Total spending on all benefit categories combined was associated with lower exposure to ≥ 4 ACEs (β coefficient= -0.11 [95% CI: -0.18, -0.04]; p= 0.005). This association suggests that for each additional $1000 spent per person living in poverty, there was an associated -0.7% point difference, or 496,379 fewer children accumulating ≥4 ACEs nationally. Increased spending in each individual benefit category was also associated with decreased reported ACEs exposure (Table 1, Figure 2; all p <0.05). Among children 0-8 years, greater average annual total spending as well as spending on cash, housing, and in-kind assistance; childcare assistance; and Medical Assistance Programs remained significantly associated with decreased reported ACEs exposure (Table 1). Conclusions: Average annual spending on benefit programs was associated with less cumulative exposure to ACEs. Investments in public benefit programs not only decrease childhood poverty but may also have broad positive effects on near- and long-term child well-being beyond the programs’ stated objectives.
Rates of Physical Abuse Screening and Detection in Infants with Brief Resolved Unexplained Events (BRUEs)
Angela Doswell, James Anderst, Joel Tieder, Henry T. Puls, and BRUE Research and Quality Improvement Network
Background: “Apparent Life-Threatening Events” (ALTEs) have been associated with child physical abuse (CPA). In 2016, “Brief Resolved Unexplained Event” (BRUE) and the development of its clinical guidelines and risk-stratification replaced ALTE. However, it is unknown if there is a similar association between BRUEs and CPA. Hypothesis/Objectives: To determine the rate of CPA in infants presenting with a BRUE, examine differences between infants with and without CPA, and to examine rates of diagnostic testing used to detect CPA. Methods: This study was part of the BRUE Research and Quality Improvement Network, composed of 15 hospitals. Subjects were infants presenting with BRUE in emergency department or inpatient settings. Subjects were followed from BRUE presentation through the first year of life for possible diagnosis of CPA at either initial BRUE or subsequent presentations. The primary outcome was CPA diagnosis at either initial BRUE or subsequent presentations. CPA was the only maltreatment type identified. The secondary outcomes were minor evidence of trauma and diagnostic testing used to detect CPA (head imaging, skeletal survey, and/or liver transaminases) at initial BRUE presentation. Chi-square tests assessed for differences. Results/Conclusion: Of the 2036 infants presenting with a BRUE, 7 (0.3%) were diagnosed with CPA, 5 of whom had findings consistent with abusive head trauma (AHT). Only 1 infant was diagnosed with CPA (cutaneous injury) at initial BRUE presentation (<0.1%). For the remaining cases, 1 infant was diagnosed with AHT within 3 days, 1 with AHT and cutaneous injury within 31-60 days, 1 with abusive fractures within 31-60 days and 3 with AHT more than 60 days after initial BRUE presentation. Infants diagnosed with CPA were more likely to be White (85.7% vs. 48.3%, p<0.05), to exhibit color change (100% vs. 51.1%, p=0.01) and have minor evidence of trauma (14.3% vs. 0.3%, p<0.001) at initial BRUE presentation. There was no difference between CPA diagnosis and BRUE risk stratification. There were 7 (0.3%) infants with minor evidence of trauma: 1 was diagnosed with CPA, 3 were iatrogenic, 1 birth-related and 2 multiple yet nonspecific minor traumas. Of all infants, only 6.2% underwent head imaging, 7% skeletal survey, and 12.1% liver transaminases. Skeletal survey was more likely to be performed if there was minor evidence of trauma (42.9 vs. 6.9%, P <0.001) or a concerning social history (13.9% vs. 5.9%, p <0.05). Head imaging was more often performed if infants had minor evidence of trauma (71.4% vs. 6.0%; p< 0.001), family history of sudden unexplained death (10.2% vs. 6.3%; p= 0.047) or concerning social history (22.8% vs. 5.4%; p< 0.001). There was a lower rate of CPA in infants at initial BRUE presentation (<0.1%) than in infants with ALTE, although testing rates at initial BRUE presentation were also low. Minor evidence of trauma and other clinical features appeared to raise suspicion and initiate diagnostic testing to detect CPA. Further research is warranted to systematically identify and diagnose infants with BRUE at increased risk for CPA.
Examining Diagnostic Variability Among Pediatric Subspecialists in Case Examples of Infant Head Injury
Angela Doswell, Emily Killough, James Anderst, Timothy Zinkus, and Ashley Sherman
Background: Clinical presentation, imaging, and ophthalmologic findings are important factors in distinguishing between noninflicted and abusive head trauma (AHT) in infants. However, little is known about agreement between pediatric subspecialists regarding diagnosis and timing of AHT in infants. Hypothesis/Objects: The primary outcome was differences in rates of AHT diagnosis among different types of pediatric subspecialists using case examples of infant head injury. The secondary outcome was qualitative trends in clinical reasoning related to injury timing. Methods: Four case examples of infant head injury were developed into an online survey. Cases were categorized as: (1) “bilateral mixed density subdural hemorrhages (SDHs)”; (2) “hyperdense right/interhemispheric SDH”; (3) “bilateral SDHs with membranes”; and (4) “hyperdense right SDH”. Each case assessed diagnosis regarding infant head injury, likelihood of AHT diagnosis, and timing of head injury given clinical presentation, laboratory, neuroradiology, and ophthalmologic findings. Participants evaluated at least 1 possible case of AHT during their career and identified as being a part of 1 (or more) of the following 5 pediatric subspecialties: Child Abuse Pediatrics (CAP), Pediatric Emergency Medicine (PEM), Pediatric Critical Care (PCC), Neurosurgery (NS) and Pediatric Hospital Medicine (PHM). The response selected by most CAPs was the reference and compared across subspecialties using Chi-square or Fisher’s exact tests. Bonferroni corrections were used to determine statistical significance. Qualitative responses were coded individually, with more frequent responses being grouped into such categories as clinical presentation (i.e., symptoms, labs, or other information provided in clinical vignette), neuroimaging findings (i.e., SDH characteristics) and ophthalmologic findings (i.e., presence and/or type or retinal hemorrhages). Results/Conclusion: A total of 288 participants completed at least 1 case. Roughly 26.7% of participants were CAPs, and 64% of participants reported evaluating at least 26 cases of possible AHT during their careers. For case 1, 100% of CAPs diagnosed AHT with no significant difference detected across subspecialties (100% PEM, 83.3% PCC, 100% NS, and 97.1% PHM diagnosed AHT). For case 2, 57.9% of CAPs did not diagnose AHT, but significantly fewer PHM (34.9%, p=0.0061), PEM (28.0%, p<0.0001) and NS participants (24.0%, p=0.0033) did not diagnose AHT. For case 3, 72.2% of CAPs diagnosed AHT with no significant difference detected across subspecialties (73.6% PEM, 66.7% PCC, 80.8% NS, and 84.1% PHM diagnosed AHT). For case 4, 39.4% of CAPs reported uncertainty with AHT diagnosis, with no significant difference detected across subspecialties (34.8% PEM, 50.0% PCC, 42.3% NS, and 34.3% PHM reported uncertainty with AHT diagnosis). In case 1, most participants reported neuroimaging findings as most helpful with injury timing. In cases 2 through 4, most participants reported clinical presentation as most helpful with injury timing. Statistically significant diagnostic variability across pediatric subspecialties was detected in only 1 case example of infant head injury; however, variability persisted across the 3 remaining cases. Further research and/or education regarding the determination of AHT diagnosis and timing of infant head injuries is warranted to aid in the medical decision-making process and decrease diagnostic variability.
Implementation of Longitudinal Learning Curricula Results in Improved ITE Scores and ABP Certifying Examination Pass Rates
Angela Etzenhouser, Emily Killough, and Danielle Reed
OBJECTIVE: To improve In-Training Examination (ITE) Scores and American Board of Pediatrics (ABP) Certifying Examination pass rates, our program implemented two longitudinal learning curricula; the objective of this study was to evaluate the effectiveness of these curricula. BACKGROUND: In 2018, we developed the “ITE Study Plan” which requires participation for residents whose ITE score falls below the national average. Residents develop a study plan that incorporates a minimum of 10 PREP questions per week along with any additional learning modalities they wish to utilize. Progress and compliance with the study plan is monitored monthly by an Associate Program Director. In 2019, the program implemented the Structured Independent Learner Curriculum (SILC), based on the work of Dr. Kris Rooney at Lehigh Valley Reilly Children’s Hospital. The SILC curriculum is required for all residents in the program and consists of earning “credits” for completing various board-relevant learning objectives each month. For lighter rotations, 6 credits per month are required. For more time-intensive months, 3 credits per month are required. Residents obtain credits for required learning such as conference attendance, online modules, and presentation of Morning Report. Additional credits can be earned according to the resident’s learning preferences and include online questions, articles, and podcasts. METHODS: In-Training Exam scores, ABP Certifying Exam scores, and ABP pass rates were tracked over a five-year period. Program scores were compared with the mean scores of all programs published with the ITE and ABP score reports. RESULTS: Since implementation of these two measures, our program has seen increased compliance with conference attendance and rotation requirements, a 330% increase in completed PREP questions, and an incremental rise in ITE scores above national means for both second- and third-year residents. ITE scores for interns remained stable over the study period. The program also saw an increase in ABP Certifying Examination pass rates, including in 2021 when nationally ABP pass rates were significantly lower. CONCLUSION: Implementation of longitudinal learning curricula improves both In-Training Examination Scores and American Board of Pediatrics Certifying Examination pass rates while reinforcing habits of life-long learning.
James Fraser, Shai Stewart MD, Kristen L. Sayers, Amy L. Pierce, Beth A. Orrick, Kayla B. Briggs, Wendy Jo Svetanoff, Tolulope A. Oyetunji MD MPH, Shawn D. St Peter, and Richard J. Hendrickson
Megan Hamner, Amanda Nedved, Holly Austin, Donna Wyly, Alaina N. Burns, Brian Lee, and Rana El Feghaly
Background: Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. However, most antibiotic stewardship programs have mainly focused on respiratory diagnoses. Children seen in the ambulatory setting for SSTIs often receive >7 days of antibiotics, although current society guidelines recommend 5-7 days for most diagnoses. Objective: To increase the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs from 58% to 75% by December 31st, 2021, in pediatric urgent care clinics (UCCs). Design/Methods: We formed a multidisciplinary team in April 2020. We completed cause-and-effect analyses and developed a driver diagram (Figure 1). Plan-Do-Study-Act (PDSA) cycle 1 provided an update on current guidelines for UCC providers. PDSA cycle 2 modified the electronic health record to display antimicrobial order sentences from shortest to longest duration. PDSA cycle 3 provided project outcome and balancing measure updates to UCC providers at regular intervals. We created a monthly report of patients 90 days and older seen in UCCs with a final diagnosis of SSTIs including impetigo, abscesses, cellulitis, erysipelas, folliculitis, paronychia, and animal bites. Our outcome measure is the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs. Process measure is the percentage of prescriptions selected from a folder. Balancing measure is the number of patients returning for SSTI within 14 days of their visit. Results are displayed using an annotated control chart. Results: The percentage of patients receiving 5-7 days of oral antibiotics during the baseline period (June 2019-June 2020) was 58%. After project initiation in April 2020, this increased to 68%, and consistently increased following PDSA cycles to a sustainable rate of >80% (Figure 2). A total of 1,971 UCC visits were included in the analysis. Process measure revealed less than 10% of providers utilize prescription folders. There was no change in balancing measure numbers. Conclusion: Prior to our project, only 58% of children seen in pediatric UCCs for SSTIs received the recommended antibiotic duration. By addressing primary drivers uncovered through QI methodology, we surpassed our goal of 75%. Additional PDSA cycles are planned along with expansion to other departments. This work will allow us to expand antibiotic stewardship efforts to other infectious diagnoses as well.
Presented at 2022 PAS Conference; Denver, CO; April 2022.
Jonathan Hartley, Jessica L. Bettenhausen, Matt Hall, James Gay, David C. Synhorst, and Jessica L. Markham
Background: Hospitalizations represent a significant driver of healthcare costs for children. Little is known about how payor type and the severity of children cared for on the pediatric medical inpatient floor impact a hospital’s financial outcomes. Objective: The primary objective of this study is to compare financial outcomes of pediatric hospitalizations to the medical inpatient floor across patient severity quartiles. Secondary objectives included financial outcomes stratified by payor type across severity quartiles. Methods: Retrospective cohort study included children aged 0-18 years discharged during calendar year 2019 from hospitals that reported clinical information to the Pediatric Health Information System database and financial data to the Revenue Management Program (Children’s Hospital Association, CHA). We excluded newborns, surgical and OB admissions, children requiring PICU or NICU, and transfers in and out. We calculated the ratio of reimbursements to costs (CCR; CCR <1.0 represents a financial liability to hospitals) and compared the CCR across severity quartiles and by payor type. A net margin median was calculated as median reimbursement minus median costs. Severity was determined using the Hospitalization Resource Intensity Score for Kids (H-Risk). Results: This study included 163,656 children within 14 children’s hospitals. Patients were divided equally among four quartiles of H-Risk with quartile 1 being the least severe and quartile 4 the most. The majority of patients had a public payor (54.4%). As severity increased the number of children with chronic complex conditions increased (CCC; 6.8% with 1 or greater CCC for quartile 1 and 78.7% for quartile 4) and length of stay increased (a geometric mean of 1.4 days for quartile 1 and 3 days for quartile 4). Overall, the CCR was 1.1 across all payors and severity levels representing a slight positive margin. Among private payors the CCR varied from 1.6 to 1.7 across severity quartiles which resulted in a median net positive margin $2,544 in quartile 1 and $7,855 in quartile 4. Among public payors the CCR varied from 0.7 to 0.8 across severity quartiles which resulted in a median net negative margin of ($1,404) in quartile 1 and ($905) in quartile 4. Conclusions: Net financial outcomes varied substantially by payor. Utilizing the CCR in conjunction with the patient severity may inform payment models and hospital operations, such as staffing models and patient placement, to ensure financial solvency.
Jonathan Hartley, Jessica L. Bettenhausen, Matt Hall, David C. Synhorst, Jessica L. Markham, and James Gay
Background: Hospitalizations represent a significant driver of healthcare costs for children. Little is known about how payor type and the severity of children cared for on the general pediatric inpatient floor impact a hospital’s financial outcomes. Objective: The primary objective of this study is to compare financial outcomes of pediatric hospitalizations to the general floor across patient severity quartiles. Secondary objectives included financial outcomes stratified by payor type across severity quartiles. Methods: Retrospective cohort study included children aged 0-18 years discharged during calendar year 2019 from hospitals that reported clinical information to the Pediatric Health Information System database and financial data to the Revenue Management Program (Children’s Hospital Association, CHA). We excluded newborns, surgical and OB admissions, children requiring PICU or NICU, and transfers in and out. We calculated the ratio of reimbursements to costs (CCR; CCR <1.0 represents a financial liability to hospitals) and compared the CCR across severity quartiles and by payor type. Severity was determined using the Hospitalization Resource Intensity Score for Kids (H-Risk). Results: This study included 287,658 children within fourteen children’s hospitals. Patients were divided among four quartiles of H-Risk with quartile one being the least severe and quartile four the most. The majority of patients were in quartile one (55.5%) and had a public payor (54.4%). As severity increased the number of children with chronic complex conditions increased (CCC; 19.5% with 1 or greater CCC for quartile one and 88.5% for quartile four) and length of stay increased (a geometric mean of 1.8 days for quartile one and 11.3 days for quartile four). Overall, the CCR was 1.1 across all payors and severity levels representing a slight financial gain. Among private payors the CCR varied from 1.5 to 1.7 across severity quartiles. The median net financial gain ranged from $2,496 in quartile one to $37,257 in quartile four. Among public payors the CCR varied from 0.7 to 0.8 across severity quartiles. The median net financial loss ranged from $1,893 in quartile one to $22,513 in quartile four. Conclusions: Not unexpectedly, the financial gains and losses were higher for patients in higher severity quartiles. However, the net gain or loss varied substantially by payor. Utilizing the CCR in conjunction with the patient severity and payor mix may inform payment models and hospital operations, such as staffing models and patient placement, to ensure financial solvency.
It is commonly believed that medical emergencies do not present to general pediatric offices. However, it has been estimated that 0.9-42 emergencies per office site/year occur. The most common presentations are respiratory in nature. However, children can also present with dehydration, seizure, psychiatric or behavioral complaints. Despite this, most offices are not prepared to handle these presentations for various reasons. Multiple studies have showed that preparedness in inpatient settings is improved with education, implementation, or protocols and deliberate practice with mock codes. However, there have been few studies in the outpatient setting. One study utilized simulation as a tool to improve preparedness in an outpatient setting. This study hopes to improve outpatient preparedness as well as identify latent safety threats in the outpatient setting by utilizing rapid cycle simulation in clinics around the Kansas City area.
Alexander Hogan, Kathyrn Kyler, and Claire Seguin
Prescription of Single Maintenance And Reliever Therapy (SMART) for moderate and severe persistent asthma is the most important and actionable improvement in the National Heart Lung Blood Institute (NHLBI) asthma guidelines for pediatric hospitalists. SMART is the use of a single inhaled corticosteroid/long acting beta agonist inhaler both as a daily preventive inhaler and as-needed for asthma symptoms. As hospitalists, we treat patients with poorly controlled asthma who will benefit from SMART asthma action plans. Despite ample evidence supporting use of SMART, implementation of such large changes in practice is challenging. Implementation science and quality improvement principles can be used to anticipate barriers and plan effective frameworks for increasing use of new guidelines in practice. Through work at our own institutions, we have identified common barriers to implementing the new SMART guidance. While no single solution is likely to lead to widespread uptake, multi-pronged efforts can support adoption of this practice change. In this session, we will review the new NHLBI asthma guidelines relevant to pediatric hospitalists, focusing on when and how to use SMART for our patients with asthma. Using historical experience in implementation of other care guidelines, we will discuss implementation barriers that have been described and may apply to SMART. We will share the experience with SMART at our own institutions and tools used for inter-disciplinary guideline dissemination and SMART implementation. Our goal is to aid attendees in creating organized changes in local practice. Attendees will receive an actionable toolkit to bolster efforts in implementation of SMART at their institutions. This toolkit will include quality improvement and implementation tools useful for targeting institution-specific barriers and tracking progress of SMART use.
Steven Johnson Syndrome/Toxic Epidermal Necrolysis Management in the Pediatric Population: The Surgeon’s Perspective
Shai Stewart MD, James Fraser, Ladonna Kearse, and Pablo Aguayo
Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis are rare, life-threatening cutaneous reactions resulting in epidermal detachment that is likened to partial thickness burns. There are sparse data with regards to wound management in the pediatric literature. We aimed to explore the current practices of pediatric-only burn centers in the Pediatric Injury Quality Improvement Collaborative to lay the framework for a standardized approach to wound care.
A 36-item survey was administered to pediatric surgeons at participating centers of the consortium. No patient specific data was collected.
Surveys were completed from 4 out of the 5 institutions. The admitting service differed amongst all centers with patients being admitted to the burn team, critical care, general pediatrics, and infectious disease. The burn team primarily managed wounds (n=4) with one institution partnering with dermatology. Complete debridement occurred at one institution, gentle cleansing at two, and no debridement at one institution. Burn consults are obtained at least within 24 hours for all but one institution, where the threshold is TBSA >10%. Most dressing changes are performed daily (n=3) by the burn nurses (n=4). Enteral feeding is initiated within 24 hours universally. All institutions use antibiotic ointment and occlusive gauze as a primary dressing.
SJS/TEN is a rare but serious disease process in children with variations in practices and limited data on best management protocols. Further details into specific management protocols and outcomes may provide insight into best practice guidelines.
Kathleen Berg, David Johnson, Ginny Nyberg, Andrew Ausmus, Christine Claeys, Emily Wilkinson, and Nicholas Clark
Background: Overutilization of continuous pulse oximetry (CPO) contributes to overdiagnosis and prolonged supplemental oxygen utilization. It may also negatively impact patient sleep, mobility, length of stay (LOS), and cost. Response times to actionable alarms increase with the number of non-actionable alarms. Our baseline data revealed an average of 29.6 pulse oximetry monitor alarms sounded for each admitted patient each day of their hospitalization. Most notably, 38.7% of pulse oximetry alarms were for ≥88% which is generally considered non-actionable.
Objective: We aimed to decrease both total pulse oximetry alarms per patient day and alarms for ≥88% per patient day by 20%, each by September 2020.
Design/Methods: This single-center quality improvement study included patients admitted to inpatient pediatric units from January 2019 to September 2020. Those in intensive care or cardiology units were excluded. Process measures were 1) percentage of patients with CPO order and 2) percentage of LOS with CPO orders in place. Outcome measures were 1) total pulse oximetry alarms per patient day and 2) alarms for ≥88% per patient day. Frequencies of high acuity transfers to intensive care and code blue events without CPO ordered served as balancing measures. Plan-Do-Study-Act cycles included: 1) changing default alarm limits from <90% to <88%, 2) changing pulse oximetry order default to intermittent rather than continuous monitoring, and 3) requiring selection of an indication for CPO from a new list within the order. Statistical process control charts monitored improvement.
Results: Our project included 18,080 patients. Process measures of percentages of patients with CPO order and of LOS with CPO order in place decreased by 29.9% (44.2% to 31.0%; Fig 1) and 29.2% (45.2% to 32.0%; Fig 2), respectively. Outcome measures of total pulse oximetry alarms and alarms ≥88% per patient day decreased by 37.2% (29.6 to 18.6; Fig 3) and by 54.0% (12.4 to 5.7; Fig 4), respectively. Balancing measures were unchanged.
Conclusion(s): Change in default pulse oximetry alarm limits was associated with decreased pulse oximetry alarms, particularly of non-actionable alarms. Changes to pulse oximetry order defaults and requirements impacted provider ordering behavior with subsequent decrease in frequency and duration of CPO orders, but had a lesser impact on alarms. Such system-level changes may be applied to reduce non-actionable cardiorespiratory monitor alarms and further reduce overall alarm burden and fatigue.
Presented at the 2021 PAS Virtual Conference
Marie Camerota, Elisabeth C. McGowan, Julie A. Hofheimer, T. Michael O'Shea, Brian S. Carter, Jennifer Helderman, Jennifer Check, Charles R. Neal, Steven L. Pastyrnak, Lynne Smith, Cynthia Loncar, Stephen Sheinkopf, Lynne Dansereau, Sheri A. DellaGrotta, and Barry Lester
Background: Infants born (PMA) are at increased risk for neurodevelopmental impairment by age 2. Prior studies have tended to examine individual outcomes separately, rather than investigating whether there are subgroups of children with distinct neurobehavioral profiles.
Objective: To determine distinct neurodevelopmental profiles in 2 year old children born cognitive, language, motor, and behavioral characteristics.
Design/Methods: NOVI (Neonatal Neurobehavior and Outcomes in Very Preterm Infants) is a multi-center study of infants born (BSID-III) subscale scores, Child Behavior Checklist (CBCL) syndrome scores, diagnosis of cerebral palsy (CP; Gross Motor Function Classification System and abnormal neurologic exam), and positive screen for autism spectrum disorder (ASD risk; Modified Checklist for Autism in Toddlers, Revised, with Follow-Up [MCHAT-R/F]). Latent profile analysis (LPA) was applied to these measures to group children into mutually exclusive profiles.
Results: Follow-up data were available for N=587/704 (83%) infants. LPA model selection statistics (e.g., Bayesian information criterion [BIC]) were used to identify a four-profile solution (Table 1; Figure 1). Children in profiles 1 (black) and 2 (blue) exhibited the best outcomes at age 2 (e.g., highest Bayley; lowest CBCL scores). Children in profile 3 (red) had the lowest Bayley scores, whereas children in profile 4 (purple) had the highest CBCL scores. Rates of CP diagnosis and ASD risk were highest in profiles 3 and 4 and lowest in profiles 1 and 2. About one-third (27%) of children were classified in one of the atypical profiles (3 or 4).
Conclusion(s): We identified four qualitatively different neurodevelopmental profiles ofcognitive, language, motor, and/or behavioral impairment. The study of profiles offers a nuanced “whole child” approach to understanding outcomes for children born very preterm.
Presented at the 2021 PAS Virtual Conference
Neonatal Gut Microbiota Alterations and Local Inflammation Induced by Escherichia coli Infection are Modified by Lactobacillus rhamnosus Prophylaxis
Susana Chavez-Bueno, Hao Xuan, Shahid Umar, Concong Zhong, Wei Yu, and Venkatesh Sampath
Background: E. coli is a leading cause of neonatal sepsis. Newborns ingest E. coli, which transcytoses the gut producing bacteremia. Lactobacillus spp. decrease E. coli gut transcytosis but the mechanisms involved in this protective effect are not well understood.
Objective: To determine the effects of Lactobacillus pretreatment on the intestinal microbiota and inflammation in neonatal rats orally infected with E. coli.
Design/Methods: Newborn rats were orally pretreated on day of life (DOL) 1 and 2 with four doses of 107 colony forming units (CFU) of Lactobacillus rhamnosus GG (LGG) or PBS. On DOL 2, pups received orally 106 CFU of neonatal E. coli bacteremia strain SCB34 or PBS. On DOL 7, distal colon with stool were collected for 16S sequencing. AbundantOTU+ was used to generate de novo operational taxonomic units (OTUs). Observed, ACE, Shannon, and Simpson indices were used for alpha diversity. Bray-Curtis and Jaccard indices were used for beta diversity. Linear discriminant analysis effect size (LEfSe) was used to determine differences at the genus level. Expression of ICAM-1, GRO1, Toll-like receptor 4 (TLR4), and Single-Immunoglobulin Interleukin-1 Related Receptor (SIGIRR) was measured in ileal homogenates by real-time PCR.
Results: Phyla distribution clearly distinguished the SCB34-infected experimental groups (Fig. 1). We also observed greater alpha diversity in the SCB34-infected groups (Fig. 2; A-D). Bray-Curtis analyses showed differences in microbial abundance between the groups receiving LGG pretreatment vs. PBS prior to SCB34 infection. However, the microbial composition of these two groups was similar per Jaccard index (Fig. 2; E-F). LEfSe results showed greater abundance of Lactobacillus in both SCB34-infected groups, and surprisingly, lower abundance of Escherichia-Shigella genera in these groups compared to controls (Fig. 3; A, B). LGG pretreatment produced a significant decrease in anaerobes including Clostridium, Romboutsia and Veillonella (Fig. 3; C-E). LGG prophylaxis significantly suppressed expression of ICAM-1, GRO-1 and TLR4, while inducing the TLR4-inhibitor, SIGIRR (Fig. 4).
Conclusion(s): LGG pretreatment significantly modified clinically relevant microbiota features of neonatal pups orally infected with E. coli, and attenuated E. coli-induced intestinal inflammation. Harnessing these relevant mechanisms afforded by probiotics such as LGG will provide novel preventive and therapeutic interventions against gut-derived neonatal sepsis.
Presented at the 2021 PAS Virtual Conference
The Association Between Age and Unrecognized and Untreated Hypertension in Children with Chronic Kidney Disease
Chloe Douglas, J Roem, Joseph Flynn, Susan Furth, Bradley A. Warady, and Susan Halbach
Background: Younger age has been associated with unrecognized hypertension (HTN) in both the general pediatric population and in children on dialysis. An increased lifetime risk of cardiovascular disease and the association of HTN with chronic kidney disease (CKD) progression make optimal treatment of elevated blood pressure (BP) a key component of CKD management. However, the role of age in the recognition and treatment of HTN in non-dialysis pediatric CKD remains unknown.
Objective: Using data from the Chronic Kidney Disease in Children (CKiD) Cohort Study, we examined the relationship between age and recognized vs. unrecognized HTN, and the frequency with which stages I and II HTN are pharmacologically treated. Among children with unrecognized HTN, we also examined the relationship between age and rates of uncontrolled BP.
Design/Methods: Subjects included children <18 years of age with CKD stages>2-4, for whom BP measurements were available. Subjects were stratified by age (0 to <7 >years, ≥7 to <13 >years, ≥13 to ≤18 years) and BP readings were classified by percentile per AAP clinical guidelines. Unrecognized HTN was defined as HTN stage 1 or 2 based on clinic BP measurement without a self-reported diagnosis of HTN. Uncontrolled BP was determined by self-reported lack of antihypertensive treatment among those with HTN. Generalized estimating equations to account for repeated measures were applied to logistic regression analyses to evaluate the associations of age with unrecognized HTN and medication use.
Results: 890 CKiD Study participants with 3,442 annual study visits met inclusion criteria. Children <7 years of age had higher rates of stage 1 or 2 HTN and lower rates of antihypertensive use compared to older children>(Table 1). 46% of children age <7 years with hypertensive BP readings had>unrecognized, untreated HTN compared to 21% of hypertensive children >13 years of age. The youngest age group was associated with higher odds of unrecognized HTN (adjusted OR 2.03) and lower odds of taking antihypertensive medication (adjusted OR 0.48). With the exception of glomerular disease etiology of CKD, other covariates were not associated with unrecognized HTN.
Conclusion(s): Children with CKD younger than age 7 years are more likely to have both underdiagnosed and undertreated HTN compared to older children. Given the impact of hypertension on CKD progression and cardiovascular disease, efforts to improve BP control in these young children are needed.
Presented at the 2021 PAS Virtual Conference