Infant With Acute Bilateral Pneumothorax During Air Transport.

In rural settings, medically complicated patients may require air transport to facilities that are capable of providing higher levels of care. Extra consideration must be given to pulmonary pathologies when considering this mode of transport. Altitude changes impact both air pressure and volume as described by Boyle's law. These changes can complicate the care of these patients in several ways. We present a case of patient with respiratory failure secondary to viral infection who developed acute bilateral pneumothorax (PTX) while mechanically ventilated during a transport on a fixed-wing aircraft. In this article we outline the unique risks of air travel on the development and progression of PTX as well as the unique challenges with diagnosis and treatment during air transport.

Impact of Payer Status on Hospitalization Outcomes in Pediatric Diabetic Ketoacidosis.

BACKGROUND: Diabetic ketoacidosis (DKA) is a life-threatening complication seen in patients suffering from type I diabetes (T1D) with a cost burden of over $5 billion in the U.S. annually. Often, children are first diagnosed with T1D when they present with DKA. Our study examines the impact of payer type on pediatric DKA. We hypothesize that Medicaid payer type negatively impacts costs and care outcomes in pediatric patients with DKA as compared to private payers. METHODS: We utilized the Agency for Healthcare Research and Quality (AHRQ) 2012 Kids' Inpatient Database (KID) for analysis. Our inclusion criterion included All Patient Refined Diagnosis Related Groups (APR-DRG) coding for T1D DKA admissions with a uniform severity and an identifiable payer of Medicaid or private insurance. RESULTS: 27,241 weighted and severity-adjusted discharges met criterion (51.6 percent Medicaid payers, 48.4 percent private). Comparing Medicaid vs. private payer status, we found: length of stay (2.24 days vs. 2.09), number of procedures received (0.13 vs. 0.12), and total charges ($16,449 vs. $16,107). Limiting analysis to a crude measure of bottom quartile income showed: length of stay (2.26 days vs. 2.14), number of procedures received (0.12 vs. 0.12), and total charges ($15,393 vs. $14,063). CONCLUSIONS: Children admitted in DKA and covered by Medicaid had longer hospitalizations, more procedures performed, and higher total costs of care. Even after controlling for socioeconomic status, similar effects persisted. Further evaluations are warranted to reveal the causative factors behind these correlative findings which suggest DKA patients receive different care depending on their payer status.

Criteria for Critical Care Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance.

OBJECTIVES: To update the American Academy of Pediatrics and Society of Critical Care Medicine's 2004 Guidelines and levels of care for PICU. DESIGN: A task force was appointed by the American College of Critical Care Medicine to follow a standardized and systematic review of the literature using an evidence-based approach. The 2004 Admission, Discharge and Triage Guidelines served as the starting point, and searches in Medline (Ovid), Embase (Ovid), and PubMed resulted in 329 articles published from 2004 to 2016. Only 21 pediatric studies evaluating outcomes related to pediatric level of care, specialized PICU, patient volume, or personnel. Of these, 13 studies were large retrospective registry data analyses, six small single-center studies, and two multicenter survey analyses. Limited high-quality evidence was found, and therefore, a modified Delphi process was used. Liaisons from the American Academy of Pediatrics were included in the panel representing critical care, surgical, and hospital medicine expertise for the development of this practice guidance. The title was amended to "practice statement" and "guidance" because Grading of Recommendations, Assessment, Development, and Evaluation methodology was not possible in this administrative work and to align with requirements put forth by the American Academy of Pediatrics. METHODS: The panel consisted of two groups: a voting group and a writing group. The panel used an iterative collaborative approach to formulate statements on the basis of the literature review and common practice of the pediatric critical care bedside experts and administrators on the task force. Statements were then formulated and presented via an online anonymous voting tool to a voting group using a three-cycle interactive forecasting Delphi method. With each cycle of voting, statements were refined on the basis of votes received and on comments. Voting was conducted between the months of January 2017 and March 2017. The consensus was deemed achieved once 80% or higher scores from the voting group were recorded on any given statement or where there was consensus upon review of comments provided by voters. The Voting Panel was required to vote in all three forecasting events for the final evaluation of the data and inclusion in this work. The writing panel developed admission recommendations by level of care on the basis of voting results. RESULTS: The panel voted on 30 statements, five of which were multicomponent statements addressing characteristics specific to PICU level of care including team structure, technology, education and training, academic pursuits, and indications for transfer to tertiary or quaternary PICU. Of the remaining 25 statements, 17 reached consensus cutoff score. Following a review of the Delphi results and consensus, the recommendations were written. CONCLUSIONS: This practice statement and level of care guidance manuscript addresses important specifications for each PICU level of care, including the team structure and resources, technology and equipment, education and training, quality metrics, admission and discharge criteria, and indications for transfer to a higher level of care. The sparse high-quality evidence led the panel to use a modified Delphi process to seek expert opinion to develop consensus-based recommendations where gaps in the evidence exist. Despite this limitation, the members of the Task Force believe that these recommendations will provide guidance to practitioners in making informed decisions regarding pediatric admission or transfer to the appropriate level of care to achieve best outcomes.

Executive Summary: Criteria for Critical Care of Infants and Children: PICU Admission, Discharge, and Triage Practice Statement and Levels of Care Guidance.

This is an executive summary of the 2019 update of the 2004 guidelines and levels of care for PICU. Since previous guidelines, there has been a tremendous transformation of Pediatric Critical Care Medicine with advancements in pediatric cardiovascular medicine, transplant, neurology, trauma, and oncology as well as improvements of care in general PICUs. This has led to the evolution of resources and training in the provision of care through the PICU. Outcome and quality research related to admission, transfer, and discharge criteria as well as literature regarding PICU levels of care to include volume, staffing, and structure were reviewed and included in this statement as appropriate. Consequently, the purposes of this significant update are to address the transformation of the field and codify a revised set of guidelines that will enable hospitals, institutions, and individuals in developing the appropriate PICU for their community needs. The target audiences of the practice statement and guidance are broad and include critical care professionals; pediatricians; pediatric subspecialists; pediatric surgeons; pediatric surgical subspecialists; pediatric imaging physicians; and other members of the patient care team such as nurses, therapists, dieticians, pharmacists, social workers, care coordinators, and hospital administrators who make daily administrative and clinical decisions in all PICU levels of care.

Pre-Guideline Trends Associated with Chest Radiograph Usage for Pediatric Community-Acquired Pneumonia in Emergency Department Settings.

BACKGROUND: Health care spending in the U.S. totaled $3 trillion in 2014 and continues to increase rapidly. Minimizing waste through clinical guidelines is a promising strategy to reduce spending without compromising patient care. In 2011, clinical guidelines recommended against the use of chest X-ray (CXR) for diagnosis of community-acquired pneumonia (CAP) in pediatric ambulatory settings. However, use of CXR has not changed post-guideline. Thus, understanding the drivers of CXR utilization prior to guideline implementation could improve guideline adherence. METHODS: Retrospective study using 2009 Nationwide Emergency Department Sample data set consisting of a representative sample of all emergency room admissions. Inclusion criteria consisted of: 18 years of age or younger and the diagnosis of outpatient CAP. Population was segmented by the presence of a CXR obtained during the visit. Socioeconomic status was determined by quartile classification of the estimated median household income based on patient ZIP code. RESULTS: In 2009, children living in wealthier ZIP codes presenting to the emergency department (ED) who were diagnosed with CAP were more likely to receive diagnostic CXR. The use of chest radiograph was not statistically correlated to gender, weekday versus weekend admission, number of diagnoses at discharge, or total ED charges. CONCLUSION: The research demonstrates a strong correlation between socioeconomic status of the pediatric patient and use of chest radiograph for CAP in the ED setting prior to 2011 guideline publication. Further research to determine the reason for this correlation could give rise to focused efforts to successfully encourage adherence to clinical practice guidelines.

The Rate of Sepsis in a National Pediatric Population, 2006 to 2012.

INTRODUCTION: The rate of pediatric severe sepsis is reported to be on the rise in the United States, increasing by approximately 6000 cases annually. The goal of this study was to determine the rate of pediatric sepsis per 100 000 inpatient discharges over time. METHODS: The 2006, 2009, and 2012 Agency for Healthcare Research and Quality Healthcare Cost Utilization Project Kid's Inpatient Databases were used to analyze the rate of sepsis in children over time. RESULTS: The rate of pediatric sepsis has increased over time from 92.8 per 100 000 in 2006 to 158.7 per 100 000 in 2012. Children less than a year old with Medicaid coverage and 3 or more procedures during hospitalization have significantly higher rates than their counterparts. CONCLUSIONS: This study helps clarify the population demographics that are at greater risk for sepsis infections. Understanding the at-risk population aids policymakers and care providers in targeting these populations and make drastic changes to sepsis policies.

Air in All the Wrong Places.

Extraluminal air can occur through a wide variety of mechanisms. Often, the free air resides in isolated regions including the thorax, the peritoneum, or the mediastinum. We present a pediatric case where there was extensive extraluminal air simultaneously within several regions, one of which has never been reported in the literature.

Financial, Resource Utilization and Mortality Impacts of Teaching Hospital Status on Pediatric Patients Admitted for Sepsis.

BACKGROUND: With the changing healthcare landscape in the United States, teaching hospitals face increasing pressure to provide medical education as well as cost-effective care. Our study investigated the financial, resource utilization and mortality impact of teaching hospital status on pediatric patients admitted with sepsis. METHODS: We conducted a retrospective, weighted statistical analysis of hospitalized children with the diagnosis of sepsis. The Agency for Healthcare Research and Quality 2009 Kids' Inpatient Database provided the data for analysis. Diagnosis of sepsis and severity of illness levels were based on All Patient Refined Diagnosis-Related Groups of 720: Septicemia and Disseminated Infections. Teaching hospital status was based on presence of training programs. Statistical analysis was conducted using STATA 12.1 (Stata Corporation, College Station, TX). RESULTS: Weighted analysis revealed 17,461 patients with sepsis-9982 in teaching and 7479 in nonteaching hospitals. When comparing all patients, length of stay (8.2 vs. 4.8, P < 0.001), number of procedures received (2.03 vs. 0.87, P < 0.001), mortality (4.7% vs. 1.6%, P < 0.001), costs per day ($2326 vs. $1736, P < 0.001) and total costs ($20,428 vs. $7960, P < 0.001) were higher in teaching hospitals. Even when stratified by severity classes, length of stay, number of procedures received and total costs were higher in teaching hospitals with no difference in mortality. CONCLUSIONS: Our study suggested that teaching hospitals provide pediatric inpatient care for sepsis at greater costs and resource utilization without a clear improvement in overall mortality rates in comparison with nonteaching hospitals.

Comparison of Transferred Versus Nontransferred Pediatric Patients Admitted for Sepsis.

OBJECTIVE: Little is known about the characteristics of pediatric patients transferred for medical care. Thus, we aimed to compare pediatric patients admitted for sepsis as transfers versus those who were not admitted as transfers. METHODS: Retrospective study using The Agency for Healthcare Research and Quality 2009 Kids' Inpatient Database. Inclusion diagnosis of sepsis based on an All Patient Refined Diagnosis-Related Group of 720: Septicemia & Disseminated Infections resulted in 16,894 patients. Transfer status was based on admission codes. Weighted statistical analysis was conducted using STATA 12.1 (Stata Corporation, College Station, TX). Institutional review board approval was obtained. RESULTS: Weighted analysis found significant differences between transferred versus nontransferred patients in the following areas: highest severity of illness subclass (45.1% vs. 18.7%, P < .001), number of chronic conditions (2.0 vs. 1.5, P < .001), teaching hospital status (85.9% vs. 54.8%, P < .001), length of stay (10.8 vs. 6.5, p<.001), number of procedures (2.9 vs. 1.4, P < .001), mortality (8.4% vs. 3.2%, P < .001), total costs ($30,626 vs. $13,677, P < .001), and daily costs ($2,901 vs. $1,887, P < .001). CONCLUSION: Our study found that patients diagnosed with sepsis and transferred are more severely ill with a higher number of chronic conditions, longer lengths of stay, more procedures performed, higher mortality, and higher total and daily costs.

Permanent Central Diabetes Insipidus as a Complication of S. pneumoniae Meningitis in the Pediatric Population.

Diabetes insipidus is a rare but recognized complication of meningitis. The occurrence of diabetes insidipus has been previously attributed to Streptococcus pneumoniae (S. pneumoniae) in a handful of patients and only once within the pediatric subpopulation. We present the clinical course of a previously healthy 2-year, 8-month-old male child ultimately diagnosed with central diabetes insipidus (CDI) secondary to S. pneumoniae meningitis. Permanent CDI following S. pneumoniae meningitis is unique to our case and has not been previously described. Following the case presentation, we describe the etiology, pathophysiology, diagnosis, and treatment of CDI. The mechanism proposed for this clinical outcome is cerebral herniation for a sufficient duration and subsequent ischemia leading to the development of permanent CDI. Providers should be aware of CDI resulting from S. pneumoniae meningitis as prompt diagnosis and management may decrease the risk of permanent hypothalamo-pituitary axis damage.

Pediatric Traumatic Brain Injury.

The purpose of this article is to provide a better understanding of pediatric traumatic brain injury and its management. Within the pediatric age group, ages 1 to 19, injuries are the number one cause of death with traumatic brain injury being involved in almost 50 percent of these cases. This, along with the fact that the medical system spends over $1 billion annually on pediatric traumatic brain injury, makes this issue both timely and relevant to health care providers. Over the course of this article the epidemiology, physiology, pathophysiology, and treatment of pediatric traumatic brain injury will be explored. Emphasis will be placed on the role of the early responder and the immediate interventions that should be considered and/or performed. The management discussed in this article follows the most recent recommendations from the 2012 edition of the Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents. Despite the focus of this article, it is important not to lose sight of the fact that an ounce of prevention is worth a pound--or, to be more precise and use the average human's brain measurements, just above three pounds--of cure.

Relationship Between Severity of Illness and Length of Stay on Costs Incurred During a Pediatric Critical Care Hospitalization.

OBJECTIVE: To estimate the impact of severity of illness and length of stay on costs incurred during a pediatric intensive care unit (PICU) hospitalization. STUDY DESIGN: This is a retrospective cohort study at an academic PICU located in the U.S. that examined 850 patients admitted to the PICU from Jan. 1 to Dec. 31, 2009. The study population was segmented into three severity levels based on pediatric risk of mortality (PRISM) III scores: low (PRISM score 0), medium (PRISM score 1-5), and high (PRISM score greater than 5). Outcome measures were total and daily PICU costs (2009 U.S. dollars). RESULTS: Eight hundred and fifty patients were admitted to the PICU during the study period. Forty-eight patients (5.6 percent) had incomplete financial data and were excluded from further analysis. Mean total PICU costs for low (n = 429), medium (n = 211), and high (n = 162) severity populations were $21,043, $37,980, and $55,620 (p < 0.001). Mean daily PICU costs for the low, medium, and high severity groups were $5,138, $5,903, and $5,595 (p = 0.02). CONCLUSIONS: Higher severity of illness resulted in higher total PICU costs. Interestingly, although daily PICU costs across severity of illness showed a statistically significant difference, the practical economic difference was minimal, emphasizing the importance of length of stay to total PICU costs. Thus, the study suggested that reducing length of stay independent of illness severity may be a practical cost control measure within the pediatric intensive care setting.