Hospital pediatrics最新文献

Background: Fatal opioid overdoses among children have increased 4-fold since 2018, driven by unintentional fentanyl overdoses in adolescents. Detailed descriptions profiling nonfatal overdoses that present to emergency departments (EDs) amidst this surge in deaths are lacking.

Methods: We performed a retrospective cross-sectional study of the Pediatric Health Information System, an administrative database of tertiary-care children's hospitals. We included children and youths aged 0 to 19 years who had an ED visit for opioid overdose from 2017 to 2022 using International Classification of Diseases, Tenth Revision codes. We excluded incomplete encounters. We examined temporal trends using Poisson regression models or quasi-Poisson models if data was overdispersed.

Results: We identified 4550 ED visits for opioid overdose. ED visits for opioid overdose rose 20.2% (incidence rate ratio [IRR], 1.0001; P < .001) from 2017 to 2022. Increases were highest among patients aged 0 to 4 and 15 to 19 years; male; those self-identifying as Black, Hispanic or multiracial; urban; and publicly insured. Children aged 0 to 4 and 15 to 19 years accounted for most visits (45.7% and 35.2%, respectively). Although synthetic opioid overdoses increased (IRR, 1.0002; P < .001) and were the predominant agent among children aged 0 to 4 years, prescription opioid overdoses were more common overall. Most adolescent overdoses were intentional. Rates of intensive care admission increased (IRR, 1.0004; P < .001). Fatal overdoses rose 200% (IRR, 1.0008; P = .02).

Conclusion and relevance: Increasing numbers of children are presenting to pediatric EDs for opioid overdose and in increasingly critical condition. Unlike fatal overdoses, most pediatric ED visits are for young children experiencing synthetic opioid overdose and adolescents with intentional prescription opioid overdose.

Objective: The birth hospitalization for infants prenatally substance-exposed (IPSEs) is a critical opportunity to connect with families and optimize the transition of care from inpatient to outpatient settings. Through qualitative interviews with clinicians and clinical staff, we sought to identify multilevel factors that impact care transitions from birth hospital to home for IPSEs and their families.

Methods: We recruited inpatient and outpatient clinicians and clinical staff (N = 17) from hospitals participating in the Colorado Hospital Substance Exposed Newborn Quality Improvement Collaborative (CHoSEN QIC), a state-based perinatal quality initiative focused on standardizing the care of IPSEs, for semistructured interviews. Multiple coders engaged in inductive thematic analysis, using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to generate thematic memos across participants.

Results: We identified facilitators and barriers within and across levels of the outer and inner context. Outer-context themes included the need for standardized patient identification, integrated care systems for effective transitions, and sociopolitical context, including challenges with changing laws and lagging policies. Inner-context themes included the value of rapport building with families, optimization of medical team communication, critical role of nonmedical team members for care coordination, and the importance of early identification of discharge disposition.

Conclusions: Participants across inner and outer contexts highlighted the importance of de-siloing clinical care groups serving families affected by substance use, including the need for enhanced communication among groups and the importance of incorporating key nonmedical personnel. Integrating care and communication across systems will be crucial next steps for optimization of care of this population.

Introduction: Adverse safety events cause significant morbidity and mortality. The Agency for Healthcare Research and Quality's (AHRQ) seven pediatric-specific quality indicators (termed PDIs) measure severe and preventable adverse outcomes. We previously demonstrated that PDI safety events disproportionately impact Black and Hispanic patients and that these disparities vary across hospitals. Positive deviance methods propose studying high performing hospitals to identify interventions that may improve care broadly. Our goal was to adapt methods used by the Centers for Medicare and Medicaid Services (CMS) to identify hospitals that excel in pediatric safety equity defined as achieving both high overall safety and low disparities. Future studies of high-performing hospitals will explore potential best practices for advancing equity in pediatric safety.

Objectives: There is considerable practice variation nationally for using high-flow nasal cannula (HFNC) to treat hospitalized children with bronchiolitis, despite an abundance of literature supporting specific practices. We developed recommendations for using HFNC based on available evidence and expert opinion.

Methods: Following the Research and Development (RAND)/University of California, Los Angeles Appropriateness Method, we conducted an exhaustive literature search for studies regarding the use of HFNC in bronchiolitis and drafted proposed use recommendations based on these findings. We convened an expert panel composed of nominees from national professional organizations with a range of professions (nursing, respiratory therapy, medicine) and clinical expertise (intensive care, emergency medicine, hospital-based care). Panelists rated recommendations for appropriateness and necessity in 3 sequential rating sessions and a moderated meeting.

Results: The 15-member panel evaluated 60 recommendations for the initiation, reassessment, escalation, and de-escalation of HFNC in bronchiolitis. The panel reached agreement on the appropriateness of HFNC for 52 of 60 recommendations and on necessity for 46 of 52. The panel agreed with practices that may curtail HFNC use, including initiating HFNC only for refractory hypoxemia or impending respiratory failure, initiating HFNC at flow rates of 1.5 to 2 L/kg/min, and discontinuing HFNC once a patient is stable on fraction of inspired oxygen of 0.21 for 1-4 hours.

Conclusions: A national expert panel agreed on the appropriateness and necessity of parameters for HFNC use in bronchiolitis. These recommendations allow for standardization of practice that may optimize outcomes and curb indiscriminate use of this respiratory support modality.

Background and objectives: Although adult clinical trials support the use of partial enteral antibiotic therapy for infective endocarditis (IE), evidence supporting oral therapy for pediatric IE is lacking. Our antimicrobial stewardship program, in partnership with local stakeholders, developed a protocol in 2023 to manage pediatric IE with enteral antibiotics following initial intravenous therapy. Here we describe the clinical course and outcomes of patients treated with partial enteral antibiotic therapy for IE after protocol implementation.

Methods: We performed a retrospective review of the first 7  months of patients treated using the IE partial oral therapy protocol. A historical comparator group was included for reference. We identified patients with IE using electronic health record International Classification of Diseases, Tenth Revision diagnoses and excluded patients with fungal endocarditis or endovascular infection without vegetations. We collected patient microbiological and laboratory data, surgical procedures, echocardiogram findings, antibiotic use, length of stay, and readmissions.

Results: We identified 12 total patients with IE during the study period; 4 patients were excluded. Eight included patients were treated with partial enteral antibiotic therapy: 4 transitioned to enteral antibiotics within the first 7  days of IE treatment, and 3 transitioned after approximately 21  days. No patient exhibited treatment failure or IE recurrence during a 90-day follow-up period. Three patients experienced adverse drug reactions that required therapy modification. There was 1 unrelated mortality.

Conclusions: All patients in this retrospective review were successfully transitioned to enteral antibiotic therapy. Partial oral treatment of pediatric IE is an emerging treatment strategy that requires future investigation.

Objective: Health care environments pose risks to both patients and care providers. This study investigates unit working conditions potentially impacting patient and provider safety concurrently to identify common risk factors for targeted interventions.

Methods: Zero-inflated negative binomial models analyzed associations between select working conditions (eg, overtime, patient census) and patient/employee safety event rates. Multivariable regression models explored adjusted effects.

Results: Patient and employee safety event rates showed little correlation, with units having higher rates in one category often showing lower rates in the other. Significant associations were found between safety events and select working conditions; however, results were inconsistent across indicators and did not apply uniformly to both safety event types.

Conclusions: Although patient and employee safety event rates were not correlated, evidence suggests common factors (unit group, registered nurse vacancy) jointly influence both outcomes. Further research on specific safety outcomes may reveal more causal associations.