Hospital admissions from a pediatric HIV care and treatment program in Malawi.

BACKGROUND: The scale up of pediatric antiretroviral treatment programs across Sub-Saharan Africa over the last decade has brought increasing numbers of children into HIV care. This patient population requiring life-long care presents new challenges in the outpatient and inpatient settings. We sought to describe hospitalizations from a large pediatric HIV treatment facility to better understand the scope of the situation and identify areas for improved care delivery. METHODS: We conducted a retrospective case series of all HIV-infected and exposed patients <18 years enrolled at Baylor College of Medicine Children's Foundation Malawi, from October 2004-October 2010. Patients admitted to the hospital on or after the day of enrollment were included. Data were extracted from electronic clinic records. Analysis was done at the patient and admission level, as some patients had multiple admissions. RESULTS: Of 5062 patients enrolled in care, 877 (17.3 %) had 1137 admissions at median age 24 months (IQR: 12-62). 191 (21.8 %) patients had multiple admissions. A high proportion of admissions occurred in patients under two years (49.4 %), those within one month of clinic enrollment (32.9 %), those with severe immune suppression (44.0 %), and those not on ART (48.5 %). The frequency of primary admission diagnoses varied across these same variables, with malnutrition, pneumonia, and malaria being the most common. CONCLUSIONS: Illness requiring hospitalization is common in HIV-infected and exposed children and these results reinforce the need for a comprehensive care package with special attention to nutrition. Strengthened programs for malaria prevention and expanded access to pneumococcal vaccine are also needed. The high burden of admissions in children under 24 months and those newly enrolled in care suggests a need for continued improvement of early infant diagnosis and provider-initiated testing programs to link patients to care before they are symptomatic. Similarly, the high proportion of admissions in those not yet started on ART emphasizes the importance of rapid initiation of ART for eligible pediatric patients.

Effect of a triage team on length of stay in a pediatric emergency department.

OBJECTIVE: This study aimed to determine the impact of a triage team on patient length of stay (LOS) overall and by patient acuity in a pediatric emergency department (ED). METHODS: We conducted a cluster randomized controlled trial in which existing ED staffing was reallocated to include a triage team. The study was conducted in an urban children's ED Monday through Friday, from 6:00 P.M. to 2:00 A.M., for 4 weeks in February 2008. Twenty study periods were randomized according to the absence or presence of a triage team (physician, nurse, and nurse assistant) that initiated evaluations of nonurgent and urgent patients. We compared patient LOS between study periods with and without triage teams, using generalized estimating equations to allow for the clustering of effects by day. RESULTS: Of the 1726 patients, 843 were seen during nontriage team times and 883 during triage team times. Overall, there was a 21-minute decrease in LOS during triage team times compared with nontriage team times, but this was not statistically significant. Stratifying by patient acuity level, LOS was significantly decreased during triage team times for nonurgent (25 minutes, P = 0.001) and urgent patients (50 minutes, P = 0.047) but prolonged for emergent patients (79 minutes, P = 0.019) and unchanged for critically ill patients. CONCLUSIONS: Overall, although we did not find a statistically significant decrease in the LOS with the use of a dedicated triage team, we did find statistically significant decreases in the stratified analysis for urgent, nonurgent patient, and discharged patients. An important reason statistical significance may not have been reached in this study may have been our hospital's current staffing model, and therefore, the use of a triage team as additional staffing versus reallocation of existing staffing may depend on an institution's current level of staffing and its ability to meet patient demand.

Patients who leave our emergency department without being seen: the Texas Children's Hospital experience.

OBJECTIVES: As the number of individuals seeking emergency care has increased during the last decade, the challenges facing emergency departments (EDs) have grown. These include overcrowding, increasing wait times, and an increasing number of patients who leave without being seen by a medical professional. We sought to describe the clinical characteristics of patients leaving the Texas Children's Hospital (TCH) ED without being seen during 1.5-year period as well as the predictors of further treatment received by these patients. METHODS: We prospectively conducted a simple random sample of patients who left the TCH ED without being seen to determine their demographic and clinical characteristics as well as their clinical outcomes. Frequencies and measures of central tendency were used to describe the study population. Univariate and multivariate analyses were conducted to determine the predictors of receiving treatment elsewhere after leaving the TCH ED. RESULTS: Almost all study patients identified a primary care provider (PCP), and the most patients who left sought care with their PCP within 8 hours. Almost half the patients arrived during the busy evening hours between 7 and 11 pm, and the median wait time before leaving was 3 hours. Almost half of the patients reported receiving treatment elsewhere, and 4% were admitted elsewhere. Those ill longer than 24 hours were almost 3 times as likely to receive treatment elsewhere. Almost all patients were clinically better by the time of telephone follow-up, and no patient had died. CONCLUSIONS: Our findings suggest that most patients who leave the ED without being seen have PCPs and seek care elsewhere after they leave. However, most patients are not sick enough to warrant admission elsewhere and probably could have waited to see their PCP rather than come to the ED.

Global gene expression profiling in infants with acute respiratory syncytial virus broncholitis demonstrates systemic activation of interferon signaling networks.

BACKGROUND: Respiratory syncytial virus (RSV) is a leading cause of pediatric lower respiratory tract infections and has a high impact on pediatric emergency department utilization. Variation in host response may influence the pathogenesis and disease severity. We evaluated global gene expression profiles to better understand the systemic host response to acute RSV bronchiolitis in infants and young children. METHODS: Patients (age ≤ 24 months) who were clinically diagnosed with acute bronchiolitis and who had a positive rapid test for RSV assay were recruited from the Texas Children's Hospital emergency department. Global gene expression of peripheral whole blood cells were analyzed in 21 cases and 37 age-matched healthy controls. Transcripts exhibiting significant upregulation and downregulation as a result of RSV infection were identified and confirmed in a subset of samples using RNA sequencing. The potential pathways affected were analyzed. RESULTS: Blood was obtained from patients with acute RSV bronchiolitis (mean age 6 months). Of these, 43% were admitted to the hospital, 52% were given intravenous fluids and 24% received oxygen. Highly significant expression differences were detected in a discovery cohort of White infants (N = 33) and validated in an independent group of African-American infants (N = 19). Individuals with mild disease (N = 15) could not be distinguished from subjects with clinically moderate disease (N = 5). Pathway enrichment analyses of the differentially expressed genes demonstrated extensive activation of the innate immune response, particularly the interferon signaling network. There was a significant downregulation of transcripts corresponding to antigen presentation.