Hospital pediatrics最新文献

Background and objectives: The 2011 American Academy of Pediatrics guidelines recommended a renal and bladder ultrasound (RBUS) after the first febrile urinary tract infection (UTI) in infants. Abnormal RBUS findings may be due to inflammation from the acute UTI or from vesicoureteral reflux (VUR), which may require a voiding cystourethrogram (VCUG) to diagnose, increasing health care costs. Our objective was to evaluate the effect of timing of imaging relative to the acute illness on abnormal dilation on RBUS and VCUG findings.

Methods: Multicenter, retrospective study of patients aged 2 to 24 months presenting with first UTI and RBUS from January 1, 2015, to December 31, 2019. Demographics, isolated pathogen, and timing of RBUS and VCUG relative to urine culture date were recorded and compared.

Results: A total of 227 patients were included. On multivariable logistic regression, increased time in days to RBUS was associated with decreased odds of abnormal dilation (adjusted odds ratio, 0.980; P = .018) in those patients meeting culture criteria for UTI (for each additional day of delay in obtaining RBUS, the adjusted odds of detecting dilation decreased by ∼2%). There was no significant association between timing of imaging and VUR on VCUG. Additionally, 32% of patients underwent RBUS who did not meet UTI culture criteria but had similar rates of abnormal dilation and VUR to those meeting UTI culture criteria.

Conclusions: Increased time to RBUS led to decreased odds of abnormal dilation, suggesting that delaying RBUS may lead to fewer false-positive results, which may limit unnecessary additional testing and reduce health care costs. Additionally, a significant number of patients who did not meet UTI culture criteria underwent RBUS but had similar results to those meeting criteria, suggesting that the previous colony-forming unit definition for UTI may be suboptimal.

Health equity is the point at which all individuals have an equal opportunity to experience optimal health and thriving. The current state of health care is far from this ideal as numerous populations experience health disparities: differences in health or health outcomes that negatively impact groups who experience systemic disadvantage. All research has the potential to widen, maintain, or close health disparities. This article focuses on key opportunities for hospitalists of all levels of research experience to conduct research that promotes health equity from project planning to disseminating results. During the planning phase, learning health equity research concepts, developing study designs in partnership with communities, and recognizing the limitations of secondary analyses are key strategies that promote health equity. Developing strategies for recruiting populations underrepresented in research helps ensure that disparities in health outcomes are identified. Rather than conducting descriptive research to identify disparities, research which aims to improve health outcomes for groups that have been marginalized is urgently needed. Study analyses should consider intersectionality and patient-centered outcomes. Finally, dissemination to both academic and community audiences, with careful attention to words and figures, can catalyze future directions, mitigate bias, and help ensure that marginalized communities benefit equitably from research findings.

Objectives: Family-centered rounds (FCR) are an important time to engage in high-value, cost-conscious care (HV3C) discussions. However, research suggests HV3C conversations occur in a minority of FCRs. Best-practice support tools can improve provider performance, but no research has evaluated whether an HV3C-focused tool may increase pediatricians' HV3C FCR discussions. This study aimed to assess if an educational and practice-based HV3C Rounding Tool's introduction would increase providers' HV3C FCR performance and competence.

Methods: This study involved a hospitalist teaching service at a tertiary-care hospital. Evidence-based HV3C Rounding Tool and Quick Reference interventions were designed for use on FCRs, using a validated tool to measure baseline and postintervention HV3C performance. Underlying family, nursing presence/participation, and other factors' impacts upon HV3C performance were also explored. Anonymous baseline and postintervention surveys compared providers' perceived competence and comfort engaging families in HV3C discussions, as well as the tools' usefulness.

Results: Out of the 197 baseline and 157 intervention encounters recorded, the tools respectively increased from 3.8 to 5.8 HV3C performance measures addressed (P < .001), with 80% of performance measures showing significant improvement (P < .002). Aside from family presence for select performance measures, the tools had an independent, significant, positive effect upon HV3C performance. Users generally reported the tools as helpful and easy to use, noting significant increases in faculty role-modeling and trainee competence practicing HV3C.

Conclusions: Introduction of HV3C Rounding and Quick Reference tools were generally perceived as helpful and beneficial, resulting in an increase of providers' HV3C discussions and care delivery during FCRs.

Objectives: Neonatal hypothermia has been shown to be commonly detected among late preterm and term infants. In preterm and very low birth weight infants, hypothermia is associated with increased morbidity and mortality. Little is known about the clinical interventions and outcomes in hypothermic late preterm and term infants. This study fills this gap in the evidence.

Methods: Single-center retrospective cohort study using electronic health record data on infants ≥35 weeks' gestation admitted to a newborn nursery from 2015 to 2021. Hypothermia was categorized by severity: none, mild (single episode, 36.0-36.4°C), and moderate or recurrent (<36.0°C and/or 2+ episodes lasting at least 2 hours). Bivariable and multivariable logistic regression examined associations between hypothermia and interventions or outcomes. Stratified analyses by effect modifiers were conducted when appropriate.

Results: Among 24 009 infants, 1111 had moderate or recurrent hypothermia. These hypothermic infants had higher odds of NICU transfer (adjusted odds ratio [aOR] 2.10, 95% confidence interval [CI] 1.68-2.60), sepsis evaluation (aOR 2.23, 95% CI 1.73-2.84), and antibiotic use (aOR 1.73, 95% CI 1.15-2.50) than infants without hypothermia. No infants with hypothermia had culture-positive sepsis, and receipt of antibiotics ≥72 hours (surrogate for culture-negative sepsis and/or higher severity of illness) was not more common in hypothermic infants. Hypothermic infants also had higher odds of blood glucose measurement and hypoglycemia, slightly higher percent weight loss, and longer lengths of stay.

Conclusions: Late preterm and term infants with hypothermia in the nursery have potentially unnecessary increased resource utilization. Evidence-based and value-driven approaches to hypothermia in this population are needed.

Objective: Health care inequities are common among individuals who speak languages other than English (LOE). Within our PICU, LOE families prefer communication via in-person interpreters (IPI). Spanish-speaking patient families are our largest LOE population; therefore, we sought to increase Spanish IPI utilization for medical updates in the PICU.

Methods: A quality improvement initiative in a 36-bed PICU included: the addition of a dedicated weekday Spanish-speaking IPI, the creation of communication tools, staff education, optimized identification of LOE families, and development of a language dashboard across multiple Plan, Do, Study, Act cycles. The primary outcome was IPI utilization rates for daily medical updates.

Results: Spanish IPI utilization for daily weekday medical updates among 442 Spanish-speaking patient families increased from a median of 39.4% at baseline to a new centerline median of 51.9% during implementation, exhibiting 66.3% (465 of 701) utilization in the final 6 months of implementation. The greatest sustained increases in Spanish IPI utilization occurred after PICU-based IPI implementation, staff education, electronic health record optimization, and a split work week between 2 PICU-based IPIs.

Conclusions: This quality improvement initiative increased Spanish IPI utilization for daily weekday medical updates in the PICU across multiple Plan, Do, Study, Act cycles. Future work will adapt these interventions to other languages and other hospital-based units.

Objectives: To determine the frequency of children with chronic respiratory failure (CRF) and home ventilator dependence undergoing surgery at a tertiary children's hospital, and to describe periprocedural characteristics and outcomes.

Methods: We conducted a retrospective cohort study of patients with CRF and home ventilator dependence who underwent noncardiac surgery from January 1, 2013, to December 31, 2019. Descriptive statistics were used to report patient and procedural characteristics. Univariable and multivariable analyses were used to assess for factors associated with 30-day readmission.

Results: We identified 416 patients who underwent 1623 procedures. Fifty-one percent of patients used transtracheal mechanical ventilation (trach/vent) support at the time of surgery; this cohort was younger (median age 5.5 vs 10.8 years) and more complex according to American Society of Anesthesiologists status compared with bilevel positive airway pressure-dependent patients. Postoperatively, compared with bilevel positive airway pressure-dependent patients, trach/vent patients were more likely to be admitted to the ICU with longer ICU length of stay (median 5 vs 2 days). Overall 30-day readmission rate was 12% (n = 193). Presence of chronic lung disease (adjusted odds ratio 1.65, 95% confidence interval 1.01-1.69) and trach/vent dependence (adjusted odds ratio 1.65, 95% confidence interval 1.02-2.67) were independently associated with increased odds for readmission.

Conclusions: Children with CRF use anesthetic and surgical services frequently and repeatedly. Those with trach/vent dependence have higher hospital and ICU resource utilization. Although overall mortality for these patients is quite low, underlying diagnoses, nuances of technology dependence, and other factors for frequent readmission require further study to optimize resource utilization and outcomes.