Hospital pediatrics最新文献

Background and objectives: The Emergency Medical Treatment and Labor Act (EMTALA) is intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (EDs). EMTALA requirements pertain to patients of all ages presenting to dedicated EDs regardless of whether facilities have dedicated pediatric specialty services. This study aims to describe EMTALA-related civil monetary penalty (CMP) settlements involving minors.

Methods: Descriptions of all EMTALA-related CMPs occurring between 2002 and 2023 were obtained from the Office of the Inspector General web site and reviewed for involvement of minors (<18 years of age) using keywords in settlement summaries. Characteristics of settlements involving minors were described and compared with settlements not involving minors.

Results: Of 260 EMTALA-related CMPs, 38 (14.6%) involved minors. Most involved failure to provide a medical screening exam (MSE) (86.8%) and/or stabilizing treatment (52.6%). Seven (18.4%) involved pregnant minors. Eleven (28.9%) involved ED staff directing a patient (or guardian) to another facility, typically by private vehicle, and another involved 2 patients referred to on-campus outpatient clinics without an MSE.

Conclusions: One in 7 CMPs related to EMTALA violations involved minors, and 1 in 5 of these minors was pregnant. One-third of CMPs involving minors included ED staff directing patients to proceed to another facility or on-campus clinic without MSE or stabilization. Findings suggest a need for providers to understand EMTALA-specific requirements for appropriate MSE, stabilization, and transfer, and for EDs at hospitals with limited pediatric services to implement policies for the evaluation of minors and protocols for transfer when indicated.

Objective: Promoting autonomy is at the core of fellowship education. Pediatric hospital medicine (PHM) fellowship programs are relatively new, and many supervising physicians are not trained on how to promote fellow autonomy. Moreover, no studies have explored fellows' perception of autonomy throughout training. To fill this gap, we explored PHM fellows' perceptions of autonomy throughout training.

Methods: PHM fellows starting fellowship in July 2021 were recruited to participate in a longitudinal qualitative study. Using self-determination theory as a sensitizing framework, the authors conducted semistructured interviews with 14 fellows throughout fellowship. Incoming data were iteratively analyzed, and codes were created from patterns in the data. Coded data were clustered into themes.

Results: Four themes developed: (1) at the beginning of fellowship, fellows valued direct observation and close supervision from their attending. (2) Initially, fellows felt pressured to make the identical clinical decision as their attending, but over the course of training, they realized their autonomous decisions could coexist with different decisions from their attending physicians. (3) At first, fellows desired attending presence to support and guide their decision making. Over time, fellows desired a coach who could provide valuable formative feedback. (4) Because of the hierarchical nature of medicine, conversations between fellows and attending physicians about autonomy were challenging to initiate.

Conclusions: Fellows' perceptions of autonomy change throughout fellowship, which should be taken into consideration as provisions of autonomy evolve through training. Our findings can inform PHM fellowship curricula and professional development around the promotion of autonomy in fellowship.

Objectives: This study seeks to identify demographic and clinical factors prompting clinician prescribing of nirmatrelvir/ritonavir to pediatric patients for management of coronavirus disease 2019 (COVID-19) infection.

Methods: Patients aged 12 to 17 years with a COVID-19 infection and nirmatrelvir/ritonavir prescription during an outpatient clinical encounter within a PEDSnet-affiliated institution between January 2022 and August 2023 were identified using electronic health record data. A multivariate logistic regression analysis was used to estimate odds of nirmatrelvir/ritonavir prescription after adjusting for various factors.

Results: A total of 20 959 patients aged 12 to 17 years were diagnosed with a COVID-19 infection on the basis of an electronic health record-documented positive polymerase chain reaction or antigen test or diagnosis during an outpatient clinical visit. Of these patients, 408 received a nirmatrelvir/ritonavir prescription within 5 days of diagnosis. Higher odds of nirmatrelvir/ritonavir treatment were associated with having chronic or complex chronic disease (chronic: odds ratio [OR] 2.50 [95% confidence interval (CI) 1.83-3.38]; complex chronic: OR 2.21 [95% CI 1.58-3.08]). Among patients with chronic disease, each additional body system conferred 1.18 times higher odds of treatment (95% CI 1.10-1.26). Compared with non-Hispanic white patients, Hispanic patients (OR 0.61 [95% CI 0.44-0.83]) had lower odds of treatment.

Conclusions: Children with chronic conditions are more likely than those without to receive nirmatrelvir/ritonavir prescriptions. However, nirmatrelvir/ritonavir prescribing to children with chronic conditions remains infrequent. Pediatric data concerning nirmatrelvir/ritonavir safety and effectiveness in preventing severe disease and hospitalization are critical optimizing clinical decision-making and use among children.

Objectives: Gender-based disparities in salary exist in multiple fields of medicine. However, there is limited data examining gender inequities in salary in pediatric hospital medicine (PHM). Our primary objective was to assess whether gender-based salary differences exist in PHM. The secondary objective was to assess if, among women, the differences in salary varied on the basis of leadership positions or self-identified race and ethnicity.

Methods: We conducted a survey-based, cross-sectional study of pediatric hospitalists in December 2021. Our primary outcomes were base and total salary, adjusted for the reported number of average weekly work hours. We performed subanalyses by presence of a leadership position, as well as race. We used a weighted t test using inverse probability weighting to compare the outcomes between genders.

Results: A total of 559 eligible people responded to our survey (51.0%). After propensity score weighting, women's mean base salary was 87.7% of men's base (95% confidence interval [CI] 79.8%-96.4%, P < .01), and women's total salary was 85.6% of men's total (95% CI 73.2%-100.0%, P = .05) salary. On subgroup analysis of respondents with a leadership position, women's total salary was 80.6% of men's total salary (95% CI 68.7%-94.4%, P < .01). Although women who identified as white had base salaries that were 86.6% of white men's base salary (95% CI 78.5%-95.5%, P < .01), there was no gender-based difference noted between respondents that identified as nonwhite (88.4% [69.9%-111.7%] for base salary, 80.3% [57.2% to 112.7%]).

Conclusions: Gender-based discrepancies in salary exists in PHM, which were increased among those with leadership roles. Continued work and advocacy are required to achieve salary equity within PHM.

Background and objectives: Current research implies overuse of diagnostic testing and overtreatment in children with tracheostomies. There are no guidelines for obtaining sputum cultures for these patients, yet they are commonly obtained without significantly affecting management or outcomes. The aim of our quality improvement project was to decrease rate of sputum cultures in this population by 50%, from 64% to 32%.

Methods: This was a single-center quality improvement project conducted in a pediatric emergency department (ED). Key drivers included: Standardized decision-making, appropriate culture collection, knowledge regarding colonization versus clinically relevant growth, and viral versus bacterial infections in this population. The study team developed an algorithm, used modification to electronic medical records orders, and provided education to drive change. Six months of preintervention and 12 months postintervention data were collected. Run charts/statistical process charts were created for the rate of cultures, length of stay, and return to the ED.

Results: There were 159 patient encounters and the rate of sputum cultures decreased from 64% at baseline to 25% without change in length of stay or increased rate at which patients returned to the ED, including during local coronavirus disease 2019 and respiratory syncytial virus surges. We observed nonrandom data patterns after introduction of algorithm resulting in centerline shifts.

Conclusions: The study team was able to introduce an algorithm coinciding with a reduction in number of sputum cultures obtained. Next steps would be determining safety and efficacy of such an algorithm over a larger population.

Background and objectives: The authors of previous work have associated the Childhood Opportunity Index (COI) with increased hospitalizations for ambulatory care sensitive conditions (ACSC). The burden of this inequity on the health care system is unknown. We sought to understand health care resource expenditure in terms of excess hospitalizations, hospital days, and cost.

Methods: We performed a retrospective cross-sectional study of the Pediatric Health Information Systems database, including inpatient hospitalizations between January 1, 2016 and December 31, 2022 for children <18 years of age. We compared ACSC hospitalizations, mortality, and cost across COI strata.

Results: We identified 2 870 121 hospitalizations among 1 969 934 children, of which 44.5% (1 277 568/2 870 121) were for ACSCs. A total of 49.1% (331 083/674 548) of hospitalizations in the very low stratum were potentially preventable, compared with 39.7% (222 037/559 003) in the very high stratum (P < .001). After adjustment, lower COI was associated with higher odds of potentially preventable hospitalization (odds ratio 1.18, 95% confidence interval [CI] 1.17-1.19). Compared with the very high COI stratum, there were a total of 137 550 (95% CI 134 582-140 517) excess hospitalizations across all other strata, resulting in an excess cost of $1.3 billion (95% CI $1.28-1.35 billion). Compared with the very high COI stratum, there were 813 (95% CI 758-871) excess deaths, with >95% from the very low and low COI strata.

Conclusions: Children with lower neighborhood opportunity have increased risk of ACSC hospitalizations. The COI may identify communities in which targeted intervention could reduce health care utilization and costs.

Background and objectives: Gender-based communication differences are described in educational online communities, but have not been rigorously evaluated in medical online communities. Understanding gender differences in communication may provide insight into gender disparities in the medical profession. Our objective was to describe gender differences in post frequency, content, and language styles on the American Academy of Pediatrics Section on Hospital Medicine (SOHM) listserv.

Methods: Posts were obtained from publicly available SOHM listserv archives. The first month of every quarter of 2019 and 2020 were reviewed. Two reviewers assigned a post topic (clinical, research, etc) and format (question vs statement) to all deidentified original posts (K = 1.0 topic, 0.89 format). Six trained reviewers assigned language styles (intraclass coefficient = 0.73, indicating good agreement).

Results: We analyzed 1592 posts: 287 original posts and 1305 responses. Frequency: Women authored 50% of posts. The 9 most frequent posters (7 men, 2 women) accounted for 19.5% of posts. Content: Men's posts had more words than women's (132.51 vs 112.3, P ≤ .01). Men were more likely to post about health policy and research (P < .001). Men were more likely to post statements compared with women (39% vs 21%, P < .001). Style: Men's posts were more likely to be coded adversarial (12.3% vs 5.5%, P < .001) authoritative (12.2% vs 6.5%, P < .001) or self-amplifying (6.5% vs 3.6%, P < .001).

Conclusions: Women contribute disproportionately fewer posts to the American Academy of Pediatrics SOHM listserv compared with their percentage in the subspecialty. We noted significant gender differences in language style and content, which may impact career development and online community inclusion.