Hospital pediatrics最新文献

Background/objectives: Adverse events (AEs) are frequent in hospitalized children and may lead to unplanned transfers to intensive care units (ICUs). ICU transfers may occur following activation of nonemergent or emergent assessments by a rapid response team (RRT). We sought to measure and characterize AEs around RRT activations and ICU transfers and whether different RRT triage mechanisms were associated with differences in AE rates or characteristics.

Methods: We performed a retrospective cohort study of hospitalized patients younger than 18 years with RRT evaluations for and transfers to ICUs. We measured AEs from hospital admission until RRT activation (pretransfer) and during the first 48 hours following ICU transfer (posttransfer). AEs identified on primary chart review underwent secondary review by 2 independent physicians who determined case classification, severity level, and preventability.

Results: In total, 699 RRT activations were reviewed, and 407 AEs were recorded. Pretransfer AE rates were higher for patients triaged emergently vs nonemergently (0.68 vs 0.52 AE/RRT, P = .03). Most AEs pretransfer resulted in temporary harm (National Coordinating Council for Medication Error Reporting and Prevention level F, 69.7%). Most AEs were preventable pre- (53.4%) and post-ICU transfer (51.6%). The most common clinical types of AEs were related to medications/fluids (38.3%), procedures (24.8%), and diagnosis (17.4%).

Conclusions: We identified high rates of AEs among patients requiring ICU triage and transfer, especially among those triaged emergently. Activation of an RRT or ICU transfer is a very high-yield trigger for AE detection.

Background: Children with medical complexity (CMC) are an evolving patient population at high risk of adverse health care outcomes while hospitalized.

Objective: Using a nationally representative cohort, we aimed to compare hospitalization resource use for CMC to non-CMC.

Methods: Using the 2022 Kids' Inpatient Database, we identified CMC by the presence of at least 1 complex chronic condition (CCCs) and grouped CMC by 1, 2, or 3 or more CCC. The outcomes were length of stay, hospitalization costs, and in-hospital mortality across CMC groupings compared with non-CMC.

Results: Of 3 169 944 pediatric hospitalizations in the United States, 389 127 (12.3%), 118 257 (3.7%), and 155 196 (4.9%) had 1 CCC, 2 CCC, and 3 or more CCC, respectively. Relative to non-CMC, each CMC group had significantly higher odds of in-hospital mortality (1 CCC: adjusted odds ratio [aOR] 31.3 [29.0, 33.7], P < .001; 2 CCC: aOR 53.5 [49.1, 58.2], P < .001; 3+ CCC: aOR 66.9 [61.1, 73.4], P < .001), longer length of stay in days (1 CCC: +3.20, [2.95, 3.44], P < .001; 2 CCC: +6.50, [5.97, 7.02], P < .001; 3+ CCC: +11.6 [10.8, 12.4], P < .001), and higher hospitalization costs (1 CCC: +$13 388 [11 947, 14 829], P < .001; 2 CCC: +$29 426 [26 233, 32 619], P < .001; 3+ CCC: +$57 426 [51 272, 63 580], P < .001).

Conclusions: We highlight substantial health services use and in-hospital mortality for CMC compared with non-CMC. Health systems can use our findings to analyze cost-effectiveness of targeted interventions for CMC, as well as advocate for policy-based changes to reduce hospital- and individual-level inequities for CMC.

Background and objectives: Researchers and health care professionals are increasingly asserting the urgent need for effective practices and policies to address child health inequities. However, there is a paucity of data on current approaches implemented in pediatric hospitals. We sought to explore health care professionals' and interest holders' perspectives on addressing health equity in Canadian pediatric academic hospitals.

Methods: We conducted an interpretative descriptive qualitative study involving semi-structured interviews with a purposive and snowball sample of pediatrics residents, staff pediatricians, allied health professionals, and key stakeholders working at pediatric academic hospitals in Canada. We conducted interviews via video conferencing between 2021 and 2023 and analyzed data using reflexive thematic analysis.

Results: We interviewed at least 1 pediatric resident and 1 staff member (including pediatricians, allied health professionals, and key stakeholders involved in health equity) at all 17 pediatric academic hospitals in Canada. Through the 42 interviewees, the following 5 main themes (along with 12 subthemes) emerged: (1) health equity was evolving across institutions; (2) institutions were navigating reactive and proactive approaches; (3) there were siloed efforts and missed opportunities for enhanced collaboration; (4) there were gaps and ethical considerations in health equity data collection; and (5) to achieve health equity throughout an organization, institutional representation and engagement was a necessity. Barriers and facilitators to health equity work were identified, as well as examples of applicable interventions.

Conclusions: There were a myriad of health equity interventions that exist in Canadian pediatric hospitals, although they were evolving and maturing. Learnings can be shared across institutions.

Objectives: The objective of this study was to characterize the prevalence, trajectory, and risk factors of acquired dysfunction following critical illness compared with pre-illness status using age-appropriate, validated screening tools.

Methods: This was a single-center prospective study of a convenience sample of children aged 1 month to 17 years who were admitted to the pediatric intensive care unit (PICU) in a tertiary academic children's hospital between May 2019 and October 2022 for more than 24 hours with expected survival. Pre-illness baseline developmental status was measured on study enrollment using validated, age-appropriate tools that assess multiple domains. Assessments were repeated 1, 6, and 12 months following PICU discharge.

Results: The median (IQR) age of 286 patients was 3.4 (0.8, 10.8) years, the median (IQR) PICU length of stay (LOS) was 2.9 (1.8, 5.8) days, and 24% received invasive mechanical ventilation (IMV). Acquired dysfunction, defined as scores at least 1 SD below the child's baseline in majority of domains, was observed in 13% of children at 1 month following discharge. In univariate analysis, acquired dysfunction was associated with female sex (18% of female vs 9% of male individuals; P = .023), IMV (23% vs 9%, respectively; P = .002), and longer median (IQR) PICU LOS (5.2 [2.0, 10.2] vs 2.8 [1.7, 5.0], respectively; P = .016). IMV was associated with acquired dysfunction in multivariable modeling (odds ratio, 2.72, 95% CI: 1.18-6.30; P = .019). At their last assessments, 15% of patients had returned to baseline in all domains; 35% of patients demonstrated persistence of acquired dysfunction in most/all domains.

Conclusions: Approximately 1 in 8 children have acquired dysfunction following PICU discharge, with significantly greater risk in those patients who received IMV; most did not fully return to baseline within 6 to 12 months.

Objective: Late preterm infants represent nearly a quarter of a million infants born in the United States annually. There is a known variation in admission location for these infants. The objective of this study was to identify the timing and reasons for transfer for late preterm infants requiring an escalation in care during the birth hospitalization.

Patients and methods: This single-center retrospective cohort study examined the birth hospitalization for late preterm infants (34 + 0 to 36 + 6 weeks) born between 2019 and 2021, specifically focusing on infants requiring an escalation to a higher level of care. Infants with congenital anomalies expecting neonatal intensive care unit (NICU) admission were excluded. The analysis included descriptive and inferential statistics.

Results: Of 1022 infants, 150 symptomatic infants were admitted to the level III/IV NICU at birth. Of the remaining 872 infants, 14% (n = 124) received escalation of care (n = 77 from level I to II, 25 from level I to III/IV, 22 from level II to III/IV). The most common reasons for escalation were need for respiratory support (n = 32, 26%), cardiorespiratory monitoring (n = 31, 25%), thermoregulation (n = 29, 23%), and dextrose-containing intravenous fluids (n = 27, 22%). Infants required escalation of care at a median of 12.5 hours after birth (IQR 4-40 hours, range 0-133), with 50% (n = 62) occurring within the first 12 hours and 67% (n = 83) within 24 hours.

Conclusions: Escalation of care for late preterm infants most frequently occurs in the first 24 hours after birth. The most frequent reasons for escalation were the need for respiratory support, followed by cardiorespiratory monitoring and thermoregulation.

Background and objective: Children with autism spectrum disorder (ASD) are more likely to be hospitalized for psychiatric disorders than their neurotypical peers. Hospitalized children with ASD are at higher risk of experiencing agitation and physical restraint use. We aimed to compare the demographics and outcomes of psychiatric boarding hospitalizations for children with ASD between 1 main campus with enhanced psychiatric resources and 2 community campuses with limited psychiatric resources in the same children's hospital system.

Methods: We conducted a retrospective cohort study of children with ASD hospitalized for psychiatric boarding and referred to psychiatry and psychology services across a children's hospital system between October 2020 and September 2024. Patients' ASD diagnosis and medical clearance were verified during psychology evaluation.

Results: During the 4-year period, 174 children with ASD experienced 347 psychiatric boarding hospitalizations across the hospital system, of which 77% were at the main campus and 23% at community campuses. The patients' median age was 13 years (IQR, 11-16) and 72% were male. The median length of stay was 6 days (IQR, 4-11), with 80% discharged to an outpatient setting. Staff injury incidence was significantly lower at the main campus than at community campuses (22% vs 42%; P = .02), but physical restraint incidence did not differ significantly between campuses.

Conclusions: Staff injuries were significantly less frequent during psychiatric boarding hospitalizations for children with ASD at the main campus with enhanced resources, but physical restraint use was not. Future research should further examine the relationship between ASD care models and safety outcomes across diverse pediatric inpatient settings.

Background: Measuring health care disparities is essential for achieving equity, yet these efforts are often limited to isolated projects. To drive meaningful and sustained change, disparities must be systematically measured and integrated into health care operations. Equity dashboards offer a powerful tool for visualizing disparities, identifying gaps, and guiding interventions. We developed an operational equity dashboard for a pediatric emergency department (PED) to integrate equity metrics into routine decision-making and quality improvement efforts.

Methods: A multidisciplinary team created an interactive dashboard using the business intelligence tool Power BI. The dashboard aggregates electronic health record data and employs statistical process control charts to track key operational metrics over time. To identify equity gaps, filters stratify data by race, ethnicity, and language, and other variables.

Results: The dashboard identified that Hispanic patients waited 12 minutes longer to see a provider than non-Hispanic patients (78 vs 66 minutes), whereas Spanish-speaking patients waited 15 minutes longer than English-speaking patients (81 vs 66 minutes). Disparities were observed primarily among lower-acuity patients; no significant differences were found among higher-acuity patients.

Conclusion: This equity dashboard embeds health equity considerations into PED operations, enabling real-time identification of disparities and supporting targeted interventions. Operationalizing equity within ED workflows is a crucial step toward advancing equitable pediatric emergency care.

Objective: To describe clinical practice patterns in diagnostic testing, antibiotic treatment, hospitalization, subspecialty consultation, and discharge recommendations for children with preseptal and orbital cellulitis across Canadian hospitals.

Methods: A cross-sectional survey of pediatric hospitalists and pediatric emergency department (ED) physicians was conducted. The survey was distributed through the Canadian Pediatric Inpatient Research Network and completed by hospital representatives. Site-level clinical management specific to clinician was assessed. Data were analyzed descriptively.

Results: Of 40 hospitals contacted (17 children's and 23 community hospitals), 32 responded (80%; 13 children's hospitals, 19 community hospitals). The most ordered tests in the ED were complete blood count (81.9%) and C-reactive protein (CRP; 81.9%). When not ordered in the ED, 20 (62.5%) pediatric inpatient services ordered CRP and 4 (12.5%) ordered erythrocyte sedimentation rate. For admitted children, computed tomography scans were ordered always or frequently by 46.2% of children's hospital pediatricians and 5.3% of community hospital pediatricians. Ophthalmology (n = 11, 84.6%), otolaryngology (n = 9, 69.2%), and infectious diseases (n = 6, 46.2%) were frequently consulted at children's hospitals. Children with preseptal cellulitis not requiring admission were usually discharged home on oral cephalexin, whereas 2 sites recommended intravenous (IV) ceftriaxone. All children admitted with orbital cellulitis received IV antibiotics initially, most commonly a third-generation cephalosporin with antianerobic and antistaphylococcal agents or a third-generation cephalosporin with an antistaphylococcal agent.

Conclusions: There is limited consensus on diagnostic tests, subspeciality consultation, and empirical antibiotic therapy for preseptal and orbital cellulitis. This survey provides insight into health system-level usage that highlights the need to develop a clinical practice guideline to help standardize management.