Hospital pediatrics最新文献

Objectives: In this study, we hypothesize that significant variation in clinical practice and adherence to the 2022 American Academy of Pediatrics (AAP) hyperbilirubinemia guidelines exists, including for direct antiglobulin test (DAT)-positive newborns.

Methods: This study was conducted through the Better Outcomes through Research for Newborns Network. Participants completed a 58-item survey inquiring about hospital demographics, screening, and management practices for neonatal hyperbilirubinemia.

Results: One hundred twenty-three birthing hospitals were contacted, with 67 participants (55% response rate). Variation existed throughout the clinical decision-making process, from bilirubin screening to management and follow-up practices. For universal screening, 76% of centers obtained a screening bilirubin between 24 and 48 hours of age, per the AAP guidelines. Sixty-nine percent of centers screen newborn of antibody-positive birthing parents for DAT positivity. Seventy-six percent of responding centers utilized the guideline recommendation to stop phototherapy at 2 mg/dL below the level where phototherapy was initiated, regardless of DAT status. Despite the higher risk for developing rebound hyperbilirubinemia, only 66% of respondents obtained a rebound bilirubin in DAT-positive infants and 49% in infants younger than 48 hours. Despite the guideline's statement, only 24% of respondents utilized a transcutaneous bilirubin measurement at least 24 hours after phototherapy discontinuation.

Conclusion: Significant practice variation and relatively low adherence to the 2022 AAP hyperbilirubinemia guidelines existed, even for DAT-positive newborns. More research is necessary to better understand the barriers to implementation of these guidelines.

Objective: Hospital-based food insecurity (HBFI) is the inability of caregivers to obtain adequate food for themselves during their child's hospital admission. This quality-improvement study aimed to reduce hospital-related food costs through the provision of caregiver meal assistance, namely meal cards for at-risk caregivers and snack bags for all caregivers.

Methods: This study took place on a general pediatric inpatient unit at a tertiary care hospital. The outcome measure was the percentage of caregivers reporting a reduction in hospital-related food costs. The process measures were as follows: (1) percentage of caregivers reporting HBFI who received the intervention, (2) percentage of caregivers screened for HBFI, and (3) caregiver satisfaction. Statistical process run charts were used to analyze the impact of the interventions.

Results: The percentage of caregivers reporting a reduction in hospital-related food costs increased from 0% to 92.9% during the study period. The percentage of caregivers reporting HBFI who accessed an intervention increased from 0% to 55% with the meal cards and ultimately reached 93.1% with the snack bags. The rate of screening for at-risk caregivers remained very low, increasing from 6% to 14%. By the end of the study period, 80% of participating caregivers were satisfied with the meal cards, and 100% were satisfied with the snack bags.

Conclusions: The caregiver meal assistance interventions increased caregiver-reported reduction in hospital-related food costs, especially following the provision of snack bags to all caregivers. This study's findings support the need for a program with a universal strategy to address caregiver HBFI.

Background and objectives: Before COVID-19, pediatric intensive care unit (PICU) admissions for bronchiolitis had a predictable seasonal variability. Since 2020, patterns have differed markedly, with a historic "surge" in late 2022 that strained hospitals nationwide. We aimed to compare patient characteristics and outcomes of critical bronchiolitis during the surge to baseline periods.

Methods: Data were obtained from the Virtual Pediatric Systems database for patients younger than 2 years with a primary diagnosis of bronchiolitis admitted to a PICU between July 2015 and December 2022. The surge period was defined as October 2022 to December 2022. The COVID-19 period was excluded. Categorical variables were compared with chi-square tests. Continuous variables were compared with Wilcoxon rank-sum tests.

Results: Data were analyzed on 63 838 patients. Admissions per center per quarter were nearly 3-fold higher in the surge compared with baseline (60.0 [41.8-132.5] vs 21.0 [9.0-44.2], P < .001). The surge was associated with large increases in noninvasive continuous positive airway pressure (22.2% vs 15.3%, P < .001) and noninvasive bilevel positive airway pressure (21.0% vs 18.6%; P < .001), with no change in intubation rates (13.3% vs 12.6%, P = .091). Relative to baseline, cardiac arrest rates doubled (0.9% vs 0.5%; P < .001) and there was an increase in acquired morbidity (decline in Pediatric Cerebral Performance Categories or Pediatric Overall Performance Category score). In a secondary analysis, including the peak period of each year, similar trends were noted.

Conclusions: The 2022 surge was characterized by historically large PICU patient volumes and increased rates of noninvasive respiratory support, cardiac arrest, and acquired morbidity. Contributing factors may include changes in host susceptibility, illness severity, clinician behavior, and institutional practices regarding noninvasive support outside the PICU.

Objective: Identifying and addressing food insecurity (FI) is a health care priority due to impacts on health outcomes, particularly in children. Screenings and interventions in outpatient settings are widely described, whereas evidence of pediatric hospital efforts in mitigating FI is limited. This study describes efforts in statewide pediatric hospitals to address household FI (HFI) and inpatient FI (IFI) and creates a conceptual model to guide nationwide hospital FI initiatives.

Methods: We conducted a mixed methods survey of staff responsible for FI work at statewide hospitals with pediatric beds; a quantitative survey (May 2023) was followed by qualitative interviews (November 2023-September 2024), with tailored questions based on survey responses. Quantitative data were summarized using descriptive statistics. Qualitative data were organized into themes, including program characteristics, internal and external partnerships, challenges, and innovative solutions.

Results: Seventeen hospitals reported a spectrum of screening methods for HFI, with positive screens referred to social work or local resources. Most assessed IFI through informal conversations. Diverse approaches to feeding caregivers were noted, most commonly meal trays, food pantries, and gift cards. Institutional support for sustainable programming was limited. Factors leading to hospital activation around FI include hospital leadership culture and engaged stakeholders.

Conclusion: Although formal screening for IFI and HFI are limited, innovative programming addressing both are evident across hospitals. Identification of key factors for activation of hospital FI work can support hospitals interested in pursuing this work. Despite barriers, hospitals can support food security through advocacy, partnerships, and innovative programs. Sustainable efforts will require funding and broader governance for accountability.

Objective: To determine if intravenous (IV) acetaminophen use in children remains a source of iatrogenic overdosing.

Methods: A cluster of 3 index cases in early 2025 stimulated a 14-year (2011-2024) retrospective study of calls from health care facilities to the California Poison Control System (CPCS) involving IV acetaminophen dosing errors in children aged 16 years or younger. All calls during this period that involved pediatric IV acetaminophen were reviewed and data abstracted. Date of call, age of child, location in the hospital, laboratory results, acetaminophen levels, intended dose, dose given, use of N-acetylcysteine (NAC), and outcomes were recorded. Descriptive statistics were used.

Results: The 3 index pediatric cases of IV acetaminophen overdose ranged from 3 to 10 times the desired dose. Two of the 3 patients were treated with NAC. The retrospective review of CPCS calls resulted in 42 additional cases in which intravenous dosing errors occurred with mean doses of 45.5 ± 36.7 mg/kg (range, 14.7-147.1 mg/kg) and mean age of 4.9 years ± 4.0 (1 day to 16 years). Two additional patients were treated with NAC. These adverse events happened in operative/perioperative areas (13 cases), 11 cases on the pediatric inpatient units, 5 in intensive care units, 12 in the emergency department, and 4 in unknown areas. No long-term adverse effects were seen in the 45 children.

Conclusion: Rare pediatric iatrogenic IV acetaminophen overdoses continue to be seen in acute care settings. Determining potential toxicity and the need for NAC remains challenging. Further efforts are needed to prevent this infrequent serious medication error.

Background: Candida species are a leading cause of central line-associated bloodstream infections (CLABSIs) in neonatal intensive care units (NICUs) with high associated morbidity and mortality. Data about facility-level factors associated with Candida CLABSI incidence in NICUs are lacking.

Methods: We analyzed Candida CLABSIs reported through the Centers for Disease Control and Prevention's National Healthcare Surveillance Network (NHSN) bloodstream infection module and assessed facility characteristics using NHSN and American Hospital Association annual surveys during 2015-2022. We assessed annual Candida CLABSI incidence/1000 central line days and fit negative binomial models to assess associations of hospital and NICU characteristics with CLABSI incidence, controlling for birthweight category and year.

Results: Among 862 NICUs, facilities with lower nurse-to-bed ratios (incidence rate ratio [IRR] = 1.33; 95% CI, 1.03-1.70) and fewer infection preventionist surveillance hours/bed (IRR = 1.33; 95% CI, 1.05-1.70) had increased Candida CLABSI incidence. Incidence was also higher in the NICUs in the lowest tertile of NICU bed size (IRR = 1.90; 95% CI, 1.42-2.53), annual neonatal admissions (IRR = 1.87; 95% CI, 1.21-2.79), and percentage of very low birthweight admissions (IRR = 2.12; 95% CI, 1.45-3.05) compared with NICUs in the highest tertile of each variable.

Conclusion: Higher Candida CLABSI rates were observed at smaller NICUs and those with lower staffing ratios, possibly reflecting lower capacity for infection prevention and control and care for neonates who are at high-risk for CLABSIs. These data may inform facility-focused or systems-level interventions to reduce Candida CLABSIs and protect vulnerable neonates.

Background: Household food insecurity (FI) and caregiver inpatient FI (ie, limited or uncertain access to adequate food during hospitalization) negatively affect children. We aimed to describe outcomes of a hospital-based intervention bundle for household/inpatient FI.

Methods: A single-arm prospective clinical trial conducted at a large children's hospital from March 2021 to March 2022 screened English- and Spanish-speaking caregivers. Caregivers with household and/or inpatient FI received the intervention bundle (complimentary hospital meals, active referral to a community-based organization [CBO] for assistance applying for public benefits and accessing food pantries). Two-week postdischarge follow-up calls were completed with caregivers enrolled in the intervention bundle, and the CBO provided 12-month post-referral outcomes. Statistical analysis described the intervention bundle feasibility (% participants who received interventions), acceptability (participant-rated comfort, helpfulness, and satisfaction), and referral outcomes.

Results: Of 1000 enrolled caregivers (English-speaking, 75%, Spanish-speaking, 25%), 54% screened positive for household and/or inpatient FI (48% household FI and 46% inpatient FI). 70% of caregivers completed the 2-week follow-up, with median scores of 10/10 comfort with FI screening, 9/10 satisfaction with complimentary trays, and 10/10 satisfaction with CBO. Twelve-month follow-up data demonstrated that the CBO had successfully connected with 62% of referred caregivers. A total of 51% of those who connected applied for Supplemental Nutrition Assistance Program (SNAP), and 86% of those who applied received SNAP benefits within 3 months.

Conclusions: FI was highly prevalent in caregivers of hospitalized children. Hospital-based interventions with a CBO successfully reached caregivers and was rated favorably. This work can inform intervention efforts as hospital FI screening programs grow.

Background and objectives: Point-of-care ultrasonography (POCUS) provides rapid diagnostic and procedural support in conditions commonly encountered by pediatric hospitalists. It has been increasingly incorporated into undergraduate and graduate medical education, yet the extent of POCUS training in pediatric hospital medicine (PHM) fellowship is unknown. This study aims to describe the current state of POCUS education in PHM fellowships, perspectives on its value, and barriers to implementation.

Methods: A survey was developed by PHM and POCUS experts and distributed electronically to PHM fellows and fellowship program directors (PDs) and associate PDs (APDs) between August and October 2022. Comparative analyses were conducted based on respondent and program characteristics.

Results: The response rate was 72% (183/253). Forty-two percent of PDs/APDs reported that their program provides POCUS training. The most common applications taught were lung, soft-tissue, and cardiac examinations and procedural guidance. Compared with PDs/APDs, fellows agreed more strongly that POCUS should be included in fellowship training (P < .001) and reported a greater desire for advanced hands-on skills (P < .001) than PDs/APDs' expectations. Barriers to training included a lack of qualified instructors, limited access to needed technology, and the absence of a standard PHM-specific curriculum.

Conclusions: More than one-third of PHM fellowship programs offer some POCUS training; however, significant barriers remain. Trainees are increasingly entering fellowship with POCUS experience, perhaps influencing their perspectives on its value and desire for higher-level skills. Expanding POCUS education in PHM fellowship offers a unique opportunity for trainees to develop clinical skills that can distinguish them as fellowship graduates and improve patient care.