Hospital pediatrics最新文献

Objective: To examine the performance of tunnelled, noncuffed central venous catheters and small-gauge peripherally inserted central catheters for infants.

Patients and methods: Single-center, retrospective cohort study analyzing patient records for all patients younger than 12 months who had a tunnelled, noncuffed central venous catheter or small-gauge (≤3 Fr) peripherally inserted central catheter inserted at an Australian pediatric hospital over 4 years (2019-2022).

Results: A total of 267 catheters (107 tunnelled, noncuffed central venous catheters and 160 peripherally inserted central catheters) were examined, from device insertion to removal. Median age of infants was 58 days (IQR 86). A change in inserting clinicians' preferences for device selection over the study period was demonstrated, with increasing use of tunnelled, noncuffed central venous catheters. Of all devices, 65.2% (n = 174) were used until the end of prescribed treatment (104 peripherally inserted central catheters [65.0%] vs 70 tunnelled, noncuffed central venous catheters [65.4%]). Rates of central line-associated bloodstream infection (n = 7; 2.6%) and venous thrombosis (n = 5; 1.9%) were low. High rates of occlusion (overall [n = 115; 43.1%]; 76 peripherally inserted central catheters [47.5%] vs 39 tunnelled, noncuffed central venous catheters [36.4%]) and dislodgement (overall [n = 53; 19.8%]; 32 peripherally inserted central catheters [20.1%] vs 21 tunnelled, noncuffed central venous catheters [19.6%]) were evident. However, there is no indication of increased odds of occlusion between the device types.

Conclusions: There was a change in clinician preference from peripherally inserted central catheters to tunnelled, noncuffed central venous catheters, and the removal rate due to complications was similar between devices.

Background: Routine chest radiographs (CXRs) are often used to monitor patients with complicated pneumonia requiring chest tubes. We aim to evaluate the following: (1) variation in CXR ordering; and (2) outcomes such as tube-related complications, length of stay (LOS), costs, and 30-day readmissions among hospitals with differing rates of CXR orders.

Methods: Using Pediatric Health Information System (PHIS) data, this study examined children aged 6 months to 18 years with complicated pneumonia receiving thoracostomy between July 2019 and June 2023. Unadjusted and adjusted proportions of number of eligible days that a CXR was obtained following thoracostomy for each encounter were calculated. At the hospital level, the median adjusted proportion of daily CXRs ordered per encounter was calculated. Hospitals were grouped into quartiles by hospital median daily CXR proportions, and adjusted outcomes were compared.

Results: Of 1817 children, 44.1% were female, and the median age was 5 years. Adjusted median (IQR) daily CXR proportion for all encounters was 0.68 (0.55, 0.81). At the hospital level, the median adjusted proportion of daily CXRs ordered ranged from 0.30 to 0.91, with 20% of hospital IQRs falling outside of the IQR for all encounters. There were no differences in postprocedural pneumothorax, repeated thoracostomy, log post-thoracostomy days, log LOS, or 30-day readmissions across quartiles; however, there were higher log costs among high-use compared with low-use hospitals.

Conclusions: Variation exists in CXR ordering among hospitals for patients with complicated pneumonia requiring chest tubes. There were no differences in most outcomes, but high-use hospitals incurred higher costs. Future studies should address clinical factors associated with chest tube complications to guide targeted approaches to CXR ordering.

Objective: Since 2016, federal law has stipulated state child welfare agencies must maintain policies and procedures to address the needs of infants with prenatal substance exposure (PSE) and their caregivers through a plan of safe care (POSC) focused on health and substance use treatment. Research into the effects of POSC across states has been slow due to a lack of accounting of states' POSC policies. The current study documents the status and contents of states' POSC policies.

Methods: We used search terms related to POSC in Nexis Uni, a legal software, to identify state statutes and regulations in effect during spring or summer 2024. We used a mixed deductive-inductive content analysis approach to identify domains of interest of POSC policies. To overcome limits of the legal search, we additionally compiled states' reports to Congress that describe their POSC policies. We calculated an accessibility rating to characterize the extent to which each state's POSC policy was available for public inspection.

Results: Every state except Illinois maintains some type of POSC policy, primarily in the form of an administrative manual, while only 18 states had enacted POSC statutes or regulations. Administrative manuals are not easily accessible to the public or clinicians. While statutes and regulations are publicly accessible, they are inconsistent regarding parts of the POSC "process" are codified. Thirty-one states had very low levels of accessibility of POSC policies.

Conclusions: Ensuring consistent and transparent intervention for families with PSE will require greater clarity in policies and additional policy implementation supports.

Objective: Effective written feedback is essential for trainee assessment in graduate medical education but is often of poor quality, leading to dissatisfaction among trainees and potential uncertainty regarding advancement decisions made by program leadership. The goal of this study was to assess the current quality of written feedback provided by pediatric hospital medicine (PHM) faculty within resident-end-of-rotation evaluation forms and describe faculty confidence, barriers, motivations, and experiences related to written feedback.

Participants and methods: We conducted a single-center cross-sectional study of PHM faculty at a free-standing children's hospital from July to December 2023. We surveyed faculty to assess knowledge, skills, and attitudes related to written feedback. We also rated the quality of written feedback within a convenience sample of resident evaluations using the Evaluation of Feedback Captured Tool (EFeCT). High-quality written feedback was defined as an EFeCT score of 4 or 5.

Results: Twenty of 24 (83%) eligible PHM faculty completed the survey. Time to reflect and write and competing work obligations were the largest barriers to providing high-quality feedback reported. Eighty percent (16/20) reported spending 15 minutes or less completing an individual evaluation. The overall mean EFeCT score was 4 out of 5 points (SD 1.4) for 66 evaluations, written by 9 participants. Action planning was present in 74% (49/66). Only 64% (42/66) described the context in which observed behaviors occurred. High-quality written feedback was possible to achieve in as little as 278 characters, or approximately 40 words; however, feedback containing more than 500 characters, or 80 to 100 words, more reliably achieved high quality.

Conclusions: Faculty understanding of context-based feedback and learner-specific action plans may represent content areas for faculty development sessions. Reframing faculty mindset around time spent writing feedback and maximizing the quality of feedback within required evaluations may be beneficial to combat the competing time constraints and work obligations faced by faculty.

Jane is a 2-year-old Black girl who presented to the emergency department after lacerating her tongue while jumping on a trampoline. She was seen several times before this encounter for previous lacerations, episodes of epistaxis, and severe ecchymoses, all of which were not completely investigated. Despite her fragmentary treatment, Jane's parents continued to advocate for her health by raising concerns to providers in the hopes of determining the cause of her recurrent bleeding; however, these concerns were often dismissed and absent from documentation. Although Jane presented to many different providers, rendering her multiple opportunities for diagnosis, her medical history was not completely explored and her care was discontinuous, resulting in a delayed diagnosis of von Willebrand disease. Jane's story brings attention to the intersectionality of health disparities and the discrimination that persists in the medical system. Her delayed diagnosis represents many others who have also been inadequately treated based on their race, gender, or socioeconomic status, and provides an opportunity to uncover where the medical system falters. Jane's story opens the discussion about (1) racism as it exists systemically, historically, and within medicine; (2) the intersectionality of gender and race, as well as the place this holds in medicine; (3) the clinical factors leading to her missed diagnosis; and (4) future strategies proposed to mitigate racism's role in medicine.