Hospital pediatrics最新文献

There is no single definition of the conceptual framework (CF) or consensus on how it is best applied in the research process. However, in this piece, the authors argue that the CF is a tool used to link the literature review, research methodology, and study design. The CF grounds the study in the previous literature, theories, and models. It helps the researcher articulate their rationale for why the study should be performed, justify their study design, and describe the lens through which they analyze a phenomenon or research question. Researchers may find the variable use of terms such as theory, theoretical framework, and CF to be confusing. The authors address the distinction between these terms and present strategies to develop and use the CF throughout the research process. The authors provide practical examples and resources for additional learning.

Background and objective: There is limited research on screening for social determinants of health (SDOH) in hospitalized pediatric patients. In this article, we describe patient characteristics related to SDOH screening in the hospital setting and examine relationships with acute care metrics.

Methods: This is a retrospective cohort study. From July 2020 to October 2021, a 14-question SDOH screener was administered to families of patients admitted or transferred to the hospital medicine service. Information was collected regarding screen results, demographics, patient comorbidities, patient complexity, and acute care metrics. Unadjusted and multivariable analyses were performed using generalized estimation equation logistic regression models.

Results: Families in 2454 (65%) patient encounters completed SDOH screening, with ≥1 need identified in 662 (27%) encounters. Families with significant odds for positive screening results in a multivariable analysis included primary language other than English (odds ratio [OR] 4.269, confidence interval [CI] 1.731-10.533) or Spanish (OR 1.419, CI 1.050-1.918), families identifying as "Black" (OR 1.675, CI 1.237-2.266) or Hispanic (OR 1.347, CI 1.057-1.717) or having a child on the complex care registry (OR 1.466, CI 1.120-1.918). A positive screening result was not associated with increased length of stay, readmission, or 2-year emergency department or acute care utilization.

Conclusions: In hospitalized pediatric patients, populations at the greatest odds for positive needs include families with primary languages other than English or Spanish, those that identified as certain races or ethnicities, or those having a child on the complex care registry. A positive SDOH screening result in this study was not associated with an increase in length of stay, readmission, or acute care utilization.

Objectives: We examined local prescribing patterns across the entire treatment course for children treated for uncomplicated urinary tract infection (UTI) to determine opportunities for antibiotic stewardship initiatives.

Methods: We conducted a retrospective review of emergency department and inpatient encounters for febrile and afebrile UTI in a children's hospital from 2021 to 2022. An antibiotic spectrum ranking was established, and providers' choices were assessed for appropriateness on the basis of the individuals' urine culture (UCx). Groups were stratified by fever presence and compared using χ2, Fisher's exact, and Mann-Whitney U tests.

Results: Of 172 encounters (83% emergency department), 99 (58%) had a positive UCx. Eighty (80%) grew Escherichia coli, with 67 (84%) being susceptible to cefazolin (minimum inhibitory concentration ≤16 mg/L). There were 229 antibiotic regimens and 39 (17%) were appropriate. Inappropriate antibiotic choices included unnecessary use of broad-spectrum antibiotics and misdiagnosed UTI. Grouping by encounter, at least 1 dose of a third cephalosporin was given in 51% of encounters, and 80% of these received it unnecessarily because of UTI misdiagnosis or suitability of a narrower-spectrum antibiotic. The median prescribed antibiotic duration was 7 days (interquartile range 7-10). Of 73 encounters with UCx growing mixed flora or a nonuropathogen, only 29 (40%) had antibiotics discontinued. Confirmed UTI was associated with fever and nitrite positivity.

Conclusions: Our study revealed high prevalence of inappropriate antibiotics, particularly unnecessary prescribing of third cephalosporin, prescriptions not supported by laboratory data, and prolonged treatment courses. Our results identify factors that can be used to support UTI treatment pathways and ensure antibiotic stewardship.

Objective: Health literacy is the ability to find, understand, and use information and services to inform health-related decisions and actions. Inadequate health literacy is associated with health disparities, poor health outcomes, and increased emergency department (ED) visits and hospitalizations. Children with medical complexity (CMC) have high rates of acute health care utilization. We examined the association of parental health literacy with acute care utilization and costs in CMC.

Methods: This cross-sectional study included parents of CMC receiving primary care at a free-standing children's hospital. We measured parental health literacy using the Single Item Literacy Screener, which measures the assistance needed to read health care materials. Our main predictor was parental health literacy, categorized as adequate versus inadequate. In a sensitivity analysis, we categorized health literacy as never needing assistance versus needing any assistance. Main outcomes were annual ED visits, hospitalizations, and associated costs.

Results: Of the 236 parents of CMC, 5.5% had inadequate health literacy. Health literacy was not associated with acute care utilization or associated costs. In our sensitivity analysis, CMC whose parents need any assistance to read health care materials had 188% higher ED costs (adjusted rate ratio 2.88 [95% confidence interval: 1.63-5.07]) and 126% higher hospitalization costs (adjusted rate ratio 2.26 [95% confidence interval: 1.49-3.44]), compared with CMC whose parents never need assistance.

Conclusions: Inadequate parental health literacy was not associated with acute care utilization. However, CMC of parents needing any assistance to read health materials had higher ED and hospitalization costs. Further multicenter studies are needed.

Background: Understanding the postoperative length of stay (LOS) by surgical procedure is important for hospital medicine clinicians involved in surgical co-management. We assessed variation in postoperative LOS for children after elective surgical procedures and risk factors for prolonged LOS.

Methods: This study is a retrospective analysis of pediatric patients undergoing elective surgical procedures between January 1, 2018 and October 1, 2021 with postoperative hospitalization for recovery at a freestanding children's hospital. The postoperative LOS (number of days) was compared across types of surgery and by the number of chronic conditions (assessed with the Agency for Healthcare Research and Quality Condition Indicator system) using multivariable quantile regression.

Results: The median (interquartile range) LOS across all 347 types of surgical procedures combined was 2 (interquartile range 1-4). Surgical procedures (n = 85) with a median LOS between 3.0 and <5.0 days (eg, spinal fusion, Chiari decompression) accounted for 20.9% of all hospitalizations (N = 12 139) and 23.1% of all postoperative bed days. Procedures (n = 46) with a median LOS of ≥5.0 days (eg, femoral osteotomy, bladder reconstruction) accounted for 15.0% and 46.8% of all hospitalizations and bed days, respectively. After controlling for the type of procedure, having ≥4 (versus none) chronic conditions was significantly associated with experiencing a prolonged LOS (90th percentile: 5.2 days); patients with 4 to 6, versus no, chronic conditions stayed a median of 1.4 (95% confidence interval [CI] 0.7-2.2) days longer, those with 7 to 9 chronic conditions stayed a median of 1.9 (95% CI 1.0-2.7) days longer, and those with ≥10 chronic conditions stayed a median of 4.0 (95% CI 3.3-4.7) days longer.

Conclusions: Hospital medicine clinicians can use the type of surgery in combination with the number of chronic conditions to estimate postoperative LOS after elective surgical procedures in children.

Objective: Managing uncertainty is a core competency of pediatric residents. However, discussing uncertainty with attending physicians can be challenging. Research is needed to understand residents' goals when communicating about uncertainty with attending physicians and how residents' perceptions of communication change during residency. Therefore, we assessed changes in residents' perceptions of their own ability to communicate uncertainty and their perceptions of attending physicians' willingness to discuss uncertainty effectively. We also identify residents' goals and challenges communicating uncertainty.

Methods: We conducted a 3-year (2018-2021) survey with 2 cohorts of residents at a US children's hospital. Of the 106 eligible residents, 100 enrolled and completed Phase I (94% response rate), 61 of the enrolled residents completed Phase II (61% response rate), and 53 completed Phase III (53% response rate). We employed hierarchical linear modeling to account for clustering of the data (Phases within residents) and to assess changes in communication efficacy and target efficacy over time. We coded open-ended responses to identify residents' communication goals and challenges.

Results: Communication efficacy and target efficacy significantly increased over time. Open-ended responses indicated that residents managed multiple task, identity, and relational goals. Residents described persistent challenges related to wanting to appear competent and working with attending physicians who were unwilling to discuss uncertainty.

Conclusions: Although residents may grow more confident communicating uncertainty, such conversations are complex and can present challenges throughout residency. Our results support the value of training on communication about uncertainty, not only for residents, but also attending physicians.

Objectives: The use of intranasal (IN) analgesics and sedatives has been studied among pediatrics patients in the emergency department and outpatient settings. However, less is known about their usage in inpatient settings. This study aims to evaluate the indications and safety profile for IN fentanyl and midazolam usage in pediatric patients admitted to a large tertiary care children's hospital.

Methods: This study is a retrospective chart review of admitted patients receiving IN fentanyl and/or midazolam over a 6-year period. Indications for medication use, medication dosages, patient characteristics, and any serious adverse drug reactions were recorded. Reported serious adverse outcomes include use of reversal agents as well as any documented respiratory depression, hypotension, or need for escalation of care.

Results: Of 156 patients included, 119 (76%) received IN midazolam alone, 20 (13%) patients received IN fentanyl alone, and 17 (11%) patients received both medications. The most common applications for IN medication administration were nasogastric tube placements (n = 62), peripheral intravenous line insertions (n = 30), peripherally-inserted central catheter placements (n = 23), and lumbar punctures (n = 16). No serious adverse events were reported.

Conclusions: This study suggests that IN fentanyl and midazolam were administered to pediatric inpatients undergoing routine procedures without serious adverse drug reactions being reported. Although these findings are encouraging, more prospective studies are needed before wider implementation of IN fentanyl and midazolam administration in pediatric inpatients.