SCAN for Abuse: Electronic Health Record-Based Universal Child Abuse Screening.

BACKGROUND: Identification of physical abuse at the point of care without a systematic approach remains inherently subjective and prone to judgement error. This study examines the implementation of an electronic health record (EHR)-based universal child injury screen (CIS) to improve detection rates of child abuse. METHODS: CIS was implemented in the EHR admission documentation for all patients age 5 or younger at a single medical center, with the following questions. 1) "Is this patient an injured/trauma patient?" 2) "If this is a trauma/injured patient, where did the injury occur?" A "Yes" response to Question 1 would alert a team of child abuse pediatricians and social workers to determine if a patient required formal child abuse clinical evaluation. Patients who received positive CIS responses, formal child abuse work-up, and/or reports to Child Protective Services (CPS) were reviewed for analysis. CPS rates from historical controls (2017-2018) were compared to post-implementation rates (2019-2021). RESULTS: Between 2019 and 2021, 14,150 patients were screened with CIS. 286 (2.0 %) patients screened received positive CIS responses. 166 (58.0 %) of these patients with positive CIS responses would not have otherwise been identified for child abuse evaluation by their treating teams. 18 (10.8 %) of the patients identified by the CIS and not by the treating team were later reported to CPS. Facility CPS reporting rates for physical abuse were 1.2 per 1000 admitted children age 5 or younger (pre-intervention) versus 4.2 per 1000 (post-intervention). CONCLUSIONS: Introduction of CIS led to increased detection suspected child abuse among children age 5 or younger. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Study of Diagnostic Test.

Outcomes of Extracorporeal Life Support Utilization for Pediatric Patients With COVID-19 Infections.

Outcomes of pediatric patients who received extracorporeal life support (ECLS) for COVID-19 remain poorly described. The aim of this multi-institutional retrospective observational study was to evaluate these outcomes and assess for prognostic factors associated with in-hospital mortality. Seventy-nine patients at 14 pediatric centers across the United States who received ECLS support for COVID-19 infections between January 2020 and July 2022 were included for analysis. Data were extracted from the electronic medical record. The median age was 14.5 years (interquartile range [IQR]: 2-17 years). Most patients were female (54.4%) and had at least one pre-existing comorbidity (84.8%), such as obesity (44.3%, median body mass index percentile: 97% [IQR: 67.5-99.0%]). Venovenous (VV) ECLS was initiated in 50.6% of patients. Median duration of ECLS was 12 days (IQR: 6.0-22.5 days) with a mean duration from admission to ECLS initiation of 5.2 ± 6.3 days. Survival to hospital discharge was 54.4%. Neurological deficits were reported in 16.3% of survivors. Nonsurvivors were of older age (13.3 ± 6.2 years vs. 9.3 ± 7.7 years, p = 0.012), more likely to receive renal replacement therapy (63.9% vs. 30.2%, p = 0.003), demonstrated longer durations from admission to ECLS initiation (7.0 ± 8.1 days vs. 3.7 ± 3.8 days, p = 0.030), and had higher rates of ECLS-related complications (91.7% vs. 69.8%, p = 0.016) than survivors. Pediatric patients with COVID-19 who received ECLS demonstrated substantial morbidity and further investigation is warranted to optimize management strategies.

Complications Associated with Subsequent Vascular Access in Pediatric ECMO Patients.

INTRODUCTION: Following ECMO decannulation, intensivists and surgeons must consider whether to reuse the cannulation site for central venous catheters (CVC) or seek remote access. This study investigates the risk of infectious complication associated with the reuse of peripheral ECMO cannulation sites for subsequent central venous access. METHODS: A retrospective review was conducted for patients aged 0-18 years, who underwent peripheral ECMO cannulation between 2009 and 2021 at a single children's hospital. RESULTS: Of the 227 charts reviewed, after ECMO decannulation, 53 patients received a CVC at the same location, 25 received a CVC at a different location, 62 received a peripherally inserted central catheter (PICC), and 87 had no subsequent vascular access placed within 30 days of decannulation. Patients with secondary access placed at the same site experienced 1 CLABSI, or 0.94 CLABSIs per 1000 line days. Patients with PICC lines after ECMO decannulation had 1 CLABSI, or 0.43 CLABSIs per 1000 line days. In comparison, the institution's hospital-wide CLABSI rate was 1.46 per 1000 line days during this same period. Although the rate of CLABSI among patients with secondary access at the site of decannulation was higher than the rate among patients with PICC lines (p = 0.79) it was lower than the institutional rate (p = 0.54), these differences did not rise to the level of statistical significance. CONCLUSION: Compared with ECMO patients with subsequent CVCs placed at an alternative access site or via PICC after decannulation, patients with contemporaneous CVC placement at the site of decannulation do not experience a significantly higher rate of CLABSIs. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective comparative study.

Quality Improvement Project to Reduce Opioid Use in Patients Undergoing Cesarean Birth.

After observing the effectiveness of Enhanced Recovery After Surgery (ERAS) protocols for gynecological surgery patients, an interdisciplinary team initiated a quality improvement project with an ERAS protocol to minimize opioid use of patients undergoing elective cesarean birth. Secondary outcomes during the three-month project included decreasing the patient's length of stay and inpatient care costs. We used the Lean Six Sigma methodology and measured aggregated patient outcomes of opioid use, length of hospital stay, and total cost. In addition, we incorporated the ERAS protocol into the electronic health record. Results showed a reduction use of morphine milligram equivalents of opioids, a slight decrease in length of hospital stay, and no change in the inpatient costs. The team recognized that implementation of an ERAS protocol is a best practice to reduce opioid use in patients undergoing a cesarean birth and decided to permanently include it in patient care processes.