Hospital pediatrics最新文献

Objectives: This paper provides an examination of: (1) the frequency and net rates of change for general pediatric inpatient (GPI) unit closures and openings nationally and by state; (2) how often closures or openings are caused by GPI unit changes only or caused by hospital-level changes; and (3) the relationship between hospital financial status and system ownership and GPI unit closures or openings.

Methods: This study used the Health Systems and Providers Database (2011-2018) plus 3 data sources on hospital closures. We enumerated GPI unit closures and openings to calculate net rates of change. Multinomial logistic regressions analyzed associations between financial distress, system ownership, and the likelihood of closing or opening a GPI unit, adjusting for hospital characteristics.

Results: Across the study period, more GPI units closed th opened for a net closure rate of 2.0% (15.7% [638 of 4069] closures minus 13.7% [558 of 4069] openings). When GPI units closed, 89.0% (568 of 638) did so in a hospital that remained operating. Hospitals with the most financial distress were not more likely to close a GPI unit than those not (odds ratio: 1.01 [95% confidence interval: 0.68-1.50]), but hospitals owned by systems were significantly less likely to close a GPI unit than those not (odds ratio: 0.66 [95% confidence interval: 0.47-0.91]).

Conclusions: Overall, more GPI units closed than opened, and closures mostly involved hospitals that otherwise remained operational. A hospital's overall financial distress was not associated with GPI unit closures, whereas being owned by a system was associated with fewer closures.

Background and objectives: Children with medical complexity (CMC) experience increased risk of adverse events during and after hospitalization, and these risks are even greater for CMC whose caregiver has a preferred language other than English. Because many adverse events for CMC may be attributable to communication challenges, understanding caregiver and physician perspectives may help prevent adverse events.

Methods: We conducted semistructured interviews with Spanish-speaking caregivers of hospitalized CMC and their inpatient attending physicians. Each interview was conducted 24 to 72 hours after hospital discharge. Interviews continued until thematic sufficiency was reached. Interviews were audio recorded, transcribed, and translated verbatim. Investigators independently coded and reconciled codes using constant comparison to develop themes via inductive thematic analysis.

Results: We conducted 28 interviews (14 caregivers, 14 physicians). Three themes were identified: (1) barriers exist in providing language-concordant care in planning for transitions from hospital-to-home; (2) both physicians and caregivers perceived logistical challenges in using interpreters at the point of care; and (3) many caregivers felt uncomfortable asking physicians questions related to their child's medical management because of their language barrier. Participants also offered strategies to improve the transition from hospital to home: (1) empower families to ask questions and take notes, (2) consider the use of medical educators, and (3) improve the ability of hospital-based physicians to follow up with patients after discharge.

Conclusions: Physicians strive for language-concordant care at each stage of discharge planning. However, unresolved gaps such as the lack of interpreter availability during medical-device education, require attention to promote safe transitions from hospital to home.

Objective: Family-centered rounds (FCR) is the standard for pediatric communication, but community pediatric hospital medicine services may face barriers in implementation, including offering FCR to families with a language preference other than English (LOE) versus those with an English preference (EP). The goal of our quality improvement project was to increase FCR from 33% to 80% over 1 year.

Methods: Interventions included an FCR checklist integrated into the electronic healthcare record (EHR-FCR checklist), staff education, visual prompts, and interpreters. Our primary outcome measure was weekly % FCR. Our main process measure was weekly % nursing documentation. To address language inclusion, we compared FCR encounters for families with LOE versus EP. The use of the checklist without interventions was assessed during the sustain period. Control charts were used to analyze measures. Fisher's exact test was used to compare FCR for families with LOE versus EP.

Results: FCR increased to 81% during the intervention period and then decreased to 73% during the sustain period. Nursing documentation increased to 93% with the EHR-FCR checklist implemented as a flowsheet. There was no statistical difference in the proportion of families with LOE versus EP who participated in FCR (84% versus 81%, P = .38) during the intervention period; a statistically higher proportion of families with LOE participated in FCR during the sustain period (87% vs 72%, P <.01).

Conclusions: We increased documented FCR on our community pediatric hospital medicine service, including FCR for families with LOE, by implementing a nursing-completed EHR-FCR checklist supported by staff education, visual prompts, and interpreters.

Background: NICU admission for hypothermia is a problem worldwide, with associated morbidity, mortality, and financial costs. Many interventions have been studied for smaller infants, but there has been little focus on infants born ≥34 weeks' gestational age (GA), though most deliveries occur at this gestation. Our primary aim was to improve the proportion of infants ≥34 weeks' GA with normal NICU admission temperature. Secondary outcomes included improvement of the proportion of normal first temperature in all infants ≥34 weeks' GA, independent of NICU admission, and improvement of predefined outcome measures.

Methods: We completed a root cause analysis, using fishbone and process mapping to determine what factors were contributing to hypothermia. A series of changes were trialed using plan-do-study-act cycles to develop a standard operating procedure, covering both vaginal and cesarean section births. Outcome measures were analyzed using a P-chart as well as traditional statistical tests.

Results: We successfully increased the proportion of infants ≥34 weeks' GA with normothermia on NICU admission from 62% to 80% without increasing hyperthermia. In addition, the interventions improved the proportion of delivery room normothermia in all infants born ≥34 weeks' GA and were associated with a decreased need for intravenous therapy for hypoglycemia and the incidence of metabolic acidosis.

Conclusions: This quality improvement initiative was successful at improving our institution's rates of normal infant temperature. The methodology used can be applied to other similar centers to improve this common problem.

Background: The Pediatric Early Warning Score (PEWS) is a clinical tool used to identify children at risk for clinical deterioration, but its utility remains debated, particularly in high-resource settings. Our objective with this study was to assess the predictive performance of the PEWS for unplanned PICU transfers after pediatric rapid response team (RRT) activation.

Methods: A retrospective cohort study at a tertiary care academic children's hospital included all hospitalized patients up to 21 years old who had RRT activations between August 2021 and July 2022. Demographic and clinical data, the primary reason for RRT activation, and the modified Brighton PEWS were collected. The primary outcome was PICU transfer following RRT activation, and the secondary outcome was rapid escalation of care within 4 hours after RRT activation. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were calculated at multiple PEWS thresholds.

Results: Of 297 RRT activations in 244 patients, 183 (63%) resulted in a PICU transfer, 75% of which were due to respiratory concerns. The PEWS was recorded in 89% of RRT activations within the preceding 4 hours. There was no significant difference in the PEWS between patients with or without PICU transfer or rapid escalation of care. The sensitivity, specificity, and AUROC of PEWS for predicting PICU transfer or rapid escalation of care were low (AUROC 0.495-0.613).

Conclusions: PEWS within 4 hours before RRT activation was a poor predictor of PICU transfer or rapid escalation care. Further work is needed to develop a more sensitive and specific tool.

Objectives: Hospitalizations for children with medical complexity (CMC) have increased substantially over the past 2 decades and constitute a disproportionate percentage of hospitalization rates and costs among children. We sought to describe the etiology and utilization for hospitalizations of CMC using the Pediatric Clinical Classification System (PECCS).

Methods: Using the 2019 Kids' Inpatient Database, we classified hospitalizations for CMC using the PECCS, which groups diagnoses into mutually exclusive, pediatric-specific categories. For the medical, surgical, and medical/surgical PECCS clinical groups, we reported diagnosis groups accounting for ≥1% of hospital encounters for that group. We described admission frequency, cost, payer, length of stay, and mortality rates within each diagnosis grouping using survey-weighted statistics.

Results: We identified 2 315 743 nonlivebirth hospitalizations, of which 712 139 (30.8%) were for CMC. Most (94.4%) hospitalizations occurred at a teaching hospital. Medical diagnosis comprised most hospitalizations (69.2%), whereas hospitalizations for surgical and medical/surgical conditions had a higher median cost. The most common diagnosis groups overall were encounters for chemotherapy, diabetic ketoacidosis, and respiratory failure, whereas the costliest were for necrotizing enterocolitis, transposition of the great vessels, and hypoplastic left heart syndrome.

Conclusions: We evaluated the most common diagnoses and their associated resource use for hospitalized CMC using the PECCS, providing a more granular view on the etiology, utilization, cost, and outcomes of hospitalizations for CMC. These topics represent high-impact areas for further research and quality efforts for CMC.