Pediatric Hospitalist Comanagement of Surgical Patients.

There are multiple reasons why pediatric hospitalists become involved in the care of surgical patients. Several are related to postoperative complications or acute medical issues that arise during their hospitalization. Comanagement programs have become increasingly utilized in the care of such patients, providing a different model of collaboration between hospital medicine and surgical providers. Traditionally, pediatric hospital medicine providers were consulted only when acute needs were identified. There has been much added value seen in the use of comanagement models, especially given the increased complexity of pediatric surgical patients and the development of pediatric hospital medicine as a subspecialty. This article will discuss pediatric hospitalist comanagement of surgical patients, including program establishment, potential benefits, and services provided, as well as challenges and additional considerations. [Pediatr Ann. 2024;53(9):e320-e323.].

Universal substance use care for adolescents with chronic medical conditions: a protocol to examine equitable implementation determinants and strategies for SBIRT at a pediatric hospital.

BACKGROUND: Adolescents with chronic medical conditions (CMC) use alcohol and marijuana at levels equal to or even greater than their peers without CMC and are more likely to initiate substance use at 14 years or younger. Approximately 33% of adolescents with CMC binge drink alcohol and 20% use marijuana. When using substances, adolescents with CMC are at elevated risk for problem use and adverse consequences given their medical conditions. Although there has recently been progress integrating substance use services into adult hospitals, there has been almost no implementation of standardized substance use services into pediatric hospitals for adolescents with CMC. Screening, Brief Intervention, and Referral to Treatment (SBIRT) for adolescents is an evidence-based, public health approach to promote the early detection and intervention of risky alcohol use in high-risk youth. This paper describes a study protocol combining two leading implementation science frameworks, the Consolidated Framework for Implementation Research (CFIR) and the Health Equity Implementation framework (HEIF), to engage pediatric hospital partners (hospital staff and clinicians, patients with CMC, and caregivers) to identify and specify contextual determinants of SBIRT implementation, which can be used to derive implementation strategies to optimize SBIRT adoption, reach, and fidelity. METHOD: This study will use semi-structured interviews and focus groups with pediatric hospital partners (e.g., hospital staff and clinicians, adolescent patients, and caregivers) to identify SBIRT implementation determinants, using semi-structured interview and focus group guides that integrate CFIR and HEIF dimensions. DISCUSSION: Understanding implementation determinants is one of the first steps in the implementation science process. The use of two determinant frameworks highlighting a comprehensive set of determinants including health equity and justice will enable identification of barriers and facilitators that will then map on to strategies that address these factors. This study will serve as an essential precursor to further work evaluating the feasibility of and the degree of engagement with SBIRT among this vulnerable pediatric population.

Characteristics and Outcomes of Infants in Texas by Facility Children's Surgery Verification Status.

INTRODUCTION: The American College of Surgeons Children's Surgery Verification (CSV) status recognizes hospitals that deliver high-quality pediatric surgical care. Texas has 5 CSV centers in three cities, which may limit equitable access to care. We explored the characteristics and outcomes of infants admitted in Texas as a function of facility CSV status. MATERIALS AND METHODS: We retrospectively reviewed a state-wide hospital discharge database (2013-2021). All patients <1 y of age were included. Patients transferred to an outside hospital were excluded to avoid double counting. Descriptive statistics and chi-square analysis were performed. RESULTS: We analyzed 3,617,173 admissions, with 211,278 (6%) treated at CSV centers. CSV admissions were less likely to be inborn (46% versus 93%) and more likely to be transfers (16% versus 1%). CSV centers also had sicker patients (32% versus 13% extreme illness severity) with higher mortality rates (1% versus 0%), longer length of stay (9 ± 22 versus 4 ± 9), and higher operative rates (33% versus 20%). However, mortality was lower at CSV centers when matched for illness severity. Proportionately more patients from rural counties (9% versus 4%) and counties along the United States-Mexico border (13% versus 1%), as well as patients of Hispanic ethnicity (39% versus 33%), were treated at non-CSV centers. Meanwhile, proportionately more African Americans (21% versus 11%) were treated at CSV centers. CONCLUSIONS: CSV centers are associated with improved outcomes among patients with high illness severity. Population differences among patients treated at CSV centers compared to non-CSV centers may represent disparities in access to care and warrant further evaluation.

The New Partnership: Technology Adoption, Development, Deployment, and Diffusion.

Children's Hospital of Philadelphia (CHOP) is a preeminent leader in pediatric healthcare delivery, research, and education. CHOP has three inpatient locations, 31 primary care centers, 16 ambulatory centers, and four dedicated research buildings. CHOP's health system provides care for children from around the world and close to home in West Philadelphia and Southern New Jersey. Technology innovation has been a key element to the hospital's success during the last 165 years.

Creation and implementation of a REDCap database demonstrates engagement and impact for a hospital-based center for nursing research and evidence-based practice.

Demonstrating impact is essential for hospital-based centers for pediatric nursing research and evidence-based practice. To meet this aim, the Center for Pediatric Nursing Research & Evidence-Based Practice at Children's Hospital of Philadelphia created a Research Electronic Data Capture (REDCap) database as a project engagement tracker to (1) capture all requests for consultation, and (2) summarize the Center's multi-professional consultants' engagement in diverse projects across our large pediatric health system. We implemented our REDCap project engagement tracker six years ago and continue to utilize it as a living database. Customized reports allow us to effectively manage our daily operations and communicate our reach and value to stakeholders internal and external to our organization. With REDCap's flexibility and ease of use, this project engagement tracker can be easily shared with like organizations. And with strong partnerships, we hope to see the development of common metrics to communicate the impact of centers of nursing inquiry on a national scale.

Barriers to initiating and implementing palliative and end-of-life care for children with life-limiting conditions: a mixed-methods study in a UK children's hospital.

BACKGROUND: To ensure that children with life-limiting conditions (LLC) and their families have access to a palliative care pathway from diagnosis to death and bereavement, a better understanding of the challenges experienced by paediatric healthcare professionals caring for children with LLC is needed. AIM: To explore the barriers paediatricians face in initiating and implementing palliative and end-of-life care for children with LLC. METHODS: Due to the challenges of COVID-19, the study was performed as a service evaluation using semi-structured interviews and an online questionnaire with consultant paediatricians in general paediatrics, community paediatrics and multiple subspecialties at a UK children's hospital between December 2020 and August 2021. Twelve interviews and 18 online questionnaires were completed. Interviews were analysed using reflexive thematic analysis, and descriptive statistics were used for questionnaire responses. RESULTS: Recurring themes from both data sets were further analysed and five themes were developed: (1) Problems with the leadership of palliative and end-of-life care; (2) Problems with preparing advanced care plans; (3) Lack of training in paediatric palliative care and advanced communication; (4) Problems communicating with families; and (5) Lack of recognition of children with LLC and high-profile cases. CONCLUSIONS: We found that the barriers to effective palliative and end-of-life planning are multifaceted and pervasive, so healthcare professionals must establish clearer pathways to overcome them. Approaches suggested included (1) discussing palliative care for children with LLC at professional encounters, for example, departmental meetings, peer-review meetings and morbidity and mortality meetings and (2) advanced communication training in palliative and end-of-life care.

Clinical Characteristics of Avoidable Patient Transfers for Suspected Pediatric Appendicitis.

INTRODUCTION: Pediatric surgical care is becoming increasingly regionalized, often resulting in limited access. Interfacility transfers pose a significant financial and emotional burden to when they are potentially avoidable. Of transferred patients, we sought to identify clinical factors associated with avoidable transfers in pediatric patients with suspected appendicitis. METHODS: We performed a single-center retrospective study at an academic tertiary referral children's hospital in an urban setting. We included children who underwent interfacility transfer to our center with a transfer diagnosis of appendicitis from July 1, 2021 to June 30, 2023. Encounters were designated as either an appropriate transfer (underwent appendectomy) or an avoidable transfer (did not undergo appendectomy). Encounters treated nonoperatively for complicated appendicitis were excluded. Bivariate analysis was performed using Mann-Whitney test and chi-square tests. RESULTS: A total of 444 patients were included: 71.2% were classified as appropriate transfers and 28.8% as avoidable transfers. Patients with avoidable transfer were younger compared to those in the appropriate transfer cohort (median age 9 y, interquartile range: 7-13 versus 11 y, interquartile range: 8-14; P < 0.001). Avoidable transfers less frequently presented with the typical symptoms of fever, migratory abdominal pain, anorexia, and nausea/emesis (P = 0.005). Avoidable transfers also reported shorter symptom duration (P = 0.040) with lower median white blood cell count (P < 0.001), neutrophil percentage (P < 0.001), and C-reactive protein levels (P < 0.003). Avoidable transfers more frequently underwent repeat imaging upon arrival (42.9% versus 12.7%, P < 0.001). CONCLUSIONS: These findings highlight the importance of clinical history in children with suspected appendicitis. Younger patients without typical symptoms of appendicitis, those with a shorter duration of symptoms, and lower serum inflammatory markers may benefit from close observation without transfer.

Development and implementation of local pediatric anesthesia performance metrics at a Canadian children's hospital: a technical report.

PURPOSE: In this project, we sought to develop and implement pediatric anesthesia metrics into electronic health records (EHR) in a hospital setting to improve quality and safety of patient care. While there has been an upsurge in metric-driven health care, specific metrics catering to pediatric anesthesia remain lacking despite widespread use of EHR. The rapid proliferation and implementation of EHR presents opportunities to develop and implement metrics appropriate to local patient care, in this case pediatric anesthesia, with the strategic goal of enhancing quality and safety of patient care, while also delivering transparency in reporting of such metrics. CLINICAL FEATURES: Using a quasi-nominal consensus group design, we collected requirements from attending anesthesiologists using Agile methodology. Forty-five metrics addressing quality of care (e.g., induction experience, anesthesia delivery, unanticipated events, and postanesthetic care unit stay) and provider performance (e.g., bundle-compliance, collaboration, skills assurance) were developed. Implementation involved integration into the EHR followed by transition from PDF-based feedback to interactive Power BI (Microsoft Corporation, Redmond, WA, USA) dashboards. CONCLUSION: We introduced and implemented customized pediatric anesthesia metrics within an academic pediatric hospital; however, this framework is easily adaptable across multiple clinical specialties and institutions. In harnessing data-collecting and reporting properties of EHR, the metrics we describe provide insights that facilitate real-time monitoring and foster a culture of continuous learning in line with strategic goals of high-reliability organizations.

RéSUMé: OBJECTIF: Dans le cadre de ce projet, nous avons cherché à développer et à mettre en œuvre des mesures d'anesthésie pédiatrique dans les dossiers de santé électroniques (DSE) en milieu hospitalier afin d'améliorer la qualité et la sécurité des soins aux patient·es. Bien qu'il y ait eu une recrudescence des soins de santé guidés par les procédures d'évaluation, les mesures spécifiques à l'anesthésie pédiatrique restent insuffisantes malgré l'utilisation généralisée du DSE. La prolifération et la mise en œuvre rapides des DSE offrent des possibilités d'élaborer et de mettre en œuvre des paramètres appropriés aux soins locaux aux patient·es, dans ce cas-ci en anesthésie pédiatrique, dans le but stratégique d'améliorer la qualité et la sécurité des soins tout en assurant la transparence des communications concernant ces paramètres. CARACTéRISTIQUES CLINIQUES: À l'aide d'un modèle de groupe consensuel quasi nominal, nous avons recueilli les exigences des anesthésiologistes traitant·es à l'aide de la méthodologie Agile. Quarante-cinq paramètres portant sur la qualité des soins (p. ex., l'expérience d'induction, l'administration de l'anesthésie, les événements imprévus et le séjour en salle de réveil) et la productivité des prestataires (p. ex., l'observance des forfaits, la collaboration, l'assurance des compétences) ont été élaborés. La mise en œuvre a impliqué l'intégration dans le DSE, suivie de la transition des commentaires en format PDF vers les tableaux de bord interactifs Power BI (Microsoft Corporation, Redmond, WA, États-Unis). CONCLUSION: Nous avons introduit et mis en œuvre des mesures personnalisées de l'anesthésie pédiatrique au sein d'un hôpital pédiatrique universitaire. Cependant, ce cadre est facilement adaptable à de multiples spécialités cliniques et institutions. Parce qu'elles exploitent les propriétés de collecte de données et de communications du DSE, les mesures que nous décrivons fournissent des informations qui facilitent la surveillance en temps réel et favorisent une culture d'apprentissage continu conforme aux objectifs stratégiques des organisations à haute fiabilité.

[Latent safety threats in a pediatric emergency department: Using in situ simulation to test a new trauma room concept]. / Latente Sicherheitsmängel in einer pädiatrischen Notaufnahme: Testung eines neuen Schockraumkonzepts mithilfe von In-situ-Simulation.

INTRODUCTION: Structured emergency room concepts have been shown to contribute to patient safety. Until now there has been no uniform emergency room concept for critically ill and seriously injured children and adolescents in the emergency room at the Altona Children's Hospital in Hamburg. This concept has been newly developed in interdisciplinary cooperation and includes the use of new clinical premises as well as new responsibilities and team compositions. The introduction of new processes and rooms for handling emergencies is associated with a risk of overlooking latent safety deficiencies or detecting them only after the process has been implemented. This may have a direct impact on patient safety. Before moving to new clinical premises, in situ simulation can be helpful to identify and to resolve latent safety threats in advance. Therefore, this method was chosen to test the newly created emergency room concept in the future emergency room at the Altona Children's Hospital. METHODS: Two in situ simulations were carried out in the future real emergency room. Latent safety threats detected by the observation team and the participants (medical and nursing staff of the Altona Children's Hospital from the departments of pediatric surgery, traumatology, orthopedics, pediatrics, anesthesia, intensive care medicine, radiology, emergency medicine) were collected using free text notes after the simulations and evaluated retrospectively. In order to better deal with these latent safety threats, the observations were classified into different categories: working environment (e.g., lack of equipment, unfavorable positioning of material), process (e.g., lack of defined responsibilities in the team) and other safety threats that did not fall into one of the two categories defined. RESULTS: A total of 51 latent safety threats were identified during the two in situ simulations. Of these, 22 (43.1%) were assigned to the "working environment" category, 20 (39.2%) to the "process" category and 9 (17.7%) to the "other safety threats" category. Of the latent safety threats identified, 46 (90.2 %) could be resolved before the emergency room was put into operation. For the non-recoverable safety threats, safety concepts were developed in order to further minimize the risk of patient hazard. DISCUSSION: With the help of this study, it could be shown that the implementation of in situ simulation before the commissioning of new clinical premises and the introduction of new processes can contribute to the detection of latent safety threats in an interdisciplinary German pediatric emergency department.

The Current State of Neonatal Neurodevelopmental Follow-up Programs in North America: A Children's Hospitals Neonatal Consortium Report.

OBJECTIVE: This study aimed to determine neonatal neurodevelopmental follow-up (NDFU) practices across academic centers. STUDY DESIGN: This study was a cross-sectional survey that addressed center-specific neonatal NDFU practices within the Children's Hospitals Neonatal Consortium (CHNC). RESULTS: Survey response rate was 76%, and 97% of respondents had a formal NDFU program. Programs were commonly staffed by neonatologists (80%), physical therapists (77%), and nurse practitioners (74%). Median gestational age at birth identified for follow-up was ≤32 weeks (range 26-36). Median duration was 3 years (range 2-18). Ninety-seven percent of sites used Bayley Scales of Infant and Toddler Development, but instruments used varied across ages. Scores were recorded in discrete electronic data fields at 43% of sites. Social determinants of health data were collected by 63%. Care coordination and telehealth services were not universally available. CONCLUSION: NDFU clinics are almost universal within CHNC centers. Commonalities and variances in practice highlight opportunities for data sharing and development of best practices. KEY POINTS: · Neonatal NDFU clinics help transition high-risk infants home.. · Interdisciplinary neonatal intensive care unit follow-up brings together previously separated outpatient service lines.. · This study reviews the current state of neonatal NDFU in North America..

The 4 S's of Disaster Management Framework: A Case Study of the 2022 Pediatric Tripledemic Response in a Community Hospital.

Most children in the United States present to community hospitals for emergency department (ED) care. Those who are acutely ill and require critical care are stabilized and transferred to a tertiary pediatric hospital with intensive care capabilities. During the fall of 2022 "tripledemic," with a marked increase in viral burden, there was a nationwide surge in pediatric ED patient volume. This caused ED crowding and decreased availability of pediatric hospital intensive care beds across the United States. As a result, there was an inability to transfer patients who were critically ill out, and the need for prolonged management increased at the community hospital level. We describe the experience of a Massachusetts community ED during this surge, including the large influx in pediatric patients, the increase in those requiring critical care, and the total number of critical care hours as compared with the same time period (September to December) in 2021. To combat these challenges, the pediatric ED leadership applied a disaster management framework based on the 4 S's of space, staff, stuff, and structure. We worked collaboratively with general emergency medicine leadership, nursing, respiratory therapy, pharmacy, local clinicians, our regional health care coalition, and emergency medical services (EMS) to create and implement the pediatric surge strategy. Here, we present the disaster framework strategy, the interventions employed, and the barriers and facilitators for implementation in our community hospital setting, which could be applied to other community hospital facing similar challenges.

Improving Access to Specialty Pediatric Care: Innovative Referral and eConsult Technology in a Specialized Acute Care Hospital.

Background: The COVID-19 pandemic has exacerbated wait times for pediatric specialty care. Transformative technologies such as electronic referral (eReferral-automation of patient information) and electronic consultations (eConsult-asynchronous request for specialized advice by primary care providers) have the potential to increase timely access to specialist care. The objective of this study was to present an overview of the current state and characteristics of referrals directed to a pediatric ambulatory medical surgery center, with an emphasis on the innovative use of an eConsult system and to indicate key considerations for system improvement. Methods: This cross-sectional study was conducted at a specialized pediatric acute care hospital in Ottawa, Ontario. Secondary data were obtained over a 2-year period during the COVID-19 pandemic (2019-2022). To gain insights and identify areas of improvement related to the factors pertaining to referrals and eConsults at the process and system levels, quality improvement (QI) methodologies were employed. Descriptive statistics provide a summary of the trends and characteristics of referrals and the utilization of eConsult. Results: Among the 113,790 referrals received, 31,430 were denied. Most common reasons for referral denial were other/null (e.g., unspecified) (29.3%), inappropriate referrals (12.6%), and duplicate referrals (12.4%). Four clinics (e.g., endocrinology, cardiology, neurology, and neurosurgery) reported a total of 277 eConsults, with endocrinology accounting for 95.0% of all eConsults. QI findings revealed the need for standardized workflows among specialties and ensuring that eConsult options are accessible and integrated within the electronic medical record (EMR). Conclusions: Refining the pediatric referral management process and optimizing eConsult through existing clinical systems have the potential to improve the timeliness and quality of specialty care. The results inform future research initiatives targeting improved access to pediatric specialty care and serve as a benchmark for hospitals utilizing EMRs and eConsult.

Addressing Transportation Insecurity Improves Attendance at Posthospitalization Appointments.

BACKGROUND: Transportation influences attendance at posthospitalization appointments (PHAs). In 2017, our pediatric hospital medicine group found that our patients missed 38% of their scheduled PHAs, with several being due to transportation insecurity. To address this, we implemented a quality improvement project to perform inpatient assessment of transportation insecurity and provide mitigation with the goal of improving attendance at PHAs. METHODS: The process measure was the percentage of patients with completed transportation insecurity screening, and the outcome measure was PHA attendance. An interprofessional team performed plan-do-study-act cycles. These included educating staff about the significance of transportation insecurity, its assessment, and documentation; embedding a list of local transportation resources in discharge instructions and coaching families on using these resources; notifying primary care providers of families with transportation insecurity; and auditing PHA attendance. RESULTS: Between July 2018 and December 2019, electronic health record documentation of transportation insecurity assessment among patients on the pediatric hospital medicine service and discharged from the hospital (n = 1731) increased from 1% to 94%, families identified with transportation insecurity increased from 1.2% to 5%, and attendance at PHAs improved for all patients (62%-81%) and for those with transportation insecurity (0%-57%). Our balance measure, proportion of discharges by 2 pm, remained steady at 53%. Plan-do-study-act cycles revealed that emphasizing PHA importance, educating staff about transportation insecurity, and helping families identify and learn to use transportation resources all contributed to improvement. CONCLUSIONS: Interventions implemented during the inpatient stay to assess for and mitigate transportation insecurity led to improvement in pediatric PHA attendance.

Evaluation of a Modified SBAR Report to Physician Tool to Standardize Communication on Neonatal Transport.

OBJECTIVE: SBAR (situation, background, assessment and recommendation) is a structured format for the effective communication of critically relevant information. This tool was developed as a generic template to provide structure to the communication of clinical information between health care providers. Neonatal transport often presents clinically stressful circumstances where concise and accurate information is required to be shared clearly between multidisciplinary health care providers. A modified SBAR communication tool was designed to facilitate structured communication between nonphysician bedside care providers operating from remote sites and physicians providing decision-making support at receiving care facilities. Prospective interventional study was designed to evaluate the reliability of a "SBAR report to physician tool" in sharing clinically relevant information between multidisciplinary care providers on neonatal transport. STUDY DESIGN: The study was conducted between 2011 and 2014 by a dedicated neonatal transport service based at McMaster Children's Hospital which provides care for approximately 500 infants in Southern Ontario annually. In the preintervention phase, 50 calls were randomly selected for the evaluation and 115 consecutively recorded transport calls following adoption of the reporting tool. The quality of calls prior to and after the intervention was assessed by reviewers independently. Inter-rater agreement was also assessed for both periods. RESULTS: Inter-rater agreement between raters was moderate to perfect in most components of the SBAR "report to the physician tool" except for the assessment component, which showed fair agreement during both preintervention and postintervention periods. There was an improvement in global score (primary outcome) with a mean difference of 0.95 (95% confidence interval [CI]: 0.77-1.14; p < 0.001) and in cumulative score with a mean difference of 8.55 (95% CI: 7.26-9.84; p < 0.001) in postintervention period. CONCLUSION: The use of the SBAR report to physician tool improved the quality of clinical information shared between nonphysician members of the neonatal transport team and neonatal transport physicians. KEY POINTS: · Long-Accurate and concise information sharing is crucial for decision-making in neonatal transport.. · Information sharing between multidisciplinary teams can be enhanced by using a commonly understood information sharing template.. · The SBAR report to physician tool improves the quality of information shared between multidisciplinary team members in neonatal transport..