Improving Time to Antibiotics for Pediatric Oncology Patients With Suspected Infections: An Emergency Department-Based Quality Improvement Intervention.

OBJECTIVE: Studies in pediatric patients with fever and neutropenia demonstrate that shorter time to antibiotics is associated with a decrease in pediatric intensive care unit admissions and in-hospital mortality. In 2012, a 2-phase quality improvement intervention was implemented in a pediatric emergency department (ED) to improve care for this high-risk patient population.The objective was to determine if the introduction of (1) a rapid absolute neutrophil count (ANC) test and (2) a standardized prearrival process decreased time to antibiotics for febrile hematology/oncology(heme/onc) patients presenting to the ED. METHODS: The rapid ANC test introduced in February 2012 decreased turn-around-times in the laboratory from 60 to 10 minutes. The standardization of the prearrival communication between the heme/onc team and ED was implemented in August 2012 as part of a clinical standard work pathway for heme/onc patients who presented to the ED with fever and possible neutropenia. Time from arrival to the ED to administration of first antibiotic was measured.Data from January 2011 to December 2013 were analyzed using statistical process control. RESULTS: Seven hundred eighteen encounters for 327 patients were included. After the rapid ANC test, the proportion of patients who received antibiotics within 60 minutes of arrival increased from 47% to 60%. There was further improvement to 69% with implementation of the clinical standard work pathway. Mean time to antibiotics decreased from 83 to 65 minutes (21% decrease). CONCLUSION: This 2-phase quality improvement intervention increased the proportion of patients who received antibiotics within 60 minutes of arrival to the ED. Similar processes may be implemented in other pediatric EDs to improve timeliness of antibiotic administration.

Review of Current Care Models for Transgender Youth and Application to the Development of a Multidisciplinary Clinic - The Seattle Children's Hospital Experience.

Care of transgender and gender diverse youth is complex and requires a multidisciplinary approach. Many transgender patients and providers feel the limited availability of affirming, knowledgeable professionals is a barrier to obtaining care. Such care can be provided through a clinic with providers from different disciplines who are trained in the unique care of transgender youth. In this paper, we discuss the care guidelines for transgender youth and the unresolved challenges that need to be addressed during the development of a transgender clinic. We describe our experience at Seattle Children's Hospital in the development of a multidisciplinary Gender Clinic which incorporates the expertise of social work, mental health professionals, pediatric endocrinology, adolescent medicine, and bioethics. Other institutions may build from our experience, with the ultimate goal of further decreasing health disparities for young transgender patients.

Insurance status and risk of cancer mortality among adolescents and young adults.

BACKGROUND: Adolescents and young adults with cancer have inferior survival outcomes compared with younger pediatric patients and older adult patients. Lack of insurance may partly explain this disparity. The objective of this study was to identify associations between insurance status and both advanced-stage cancer and cancer-specific mortality. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) 18 registries, 57,981 patients ages 15 to 39 years were identified who were diagnosed between 2007 and 2010 and had complete insurance and staging information. Multinomial logistic regression models were used to identify associations between insurance type and disease stage, with the models adjusted for sex, age, and race. Cox proportional hazards models were used to estimate cancer-specific mortality. RESULTS: Overall, 84% of patients were aged ≥ 25 years, 64% were women, and 79% were privately insured. Compared with patients who had private insurance, those who had nonprivate insurance tended to present with more advanced-stage disease and to die more quickly and more commonly from their cancer. Patients ages 25 to 39 years who had Medicaid coverage or no insurance had 3.2 times and 2.4 times higher odds of having stage IV disease, respectively, than privately insured patients (95% confidence interval [CI], 3.0-3.5 times higher odds and 2.1-2.6 times higher odds, respectively). Among those with stage I/II and III/IV cancers, the risk of death was 2.9 times greater (95% CI, 2.2-3.9 times greater) and 1.7 times greater (95% CI, 1.5-1.9 times greater), respectively, than the risk for privately insured patients. Patients who died from stage III/IV cancers survived at least 2 months longer if they had private insurance. CONCLUSIONS: Among young adults, insurance status is independently associated with advanced-stage cancer and the risk of death from cancer, even for patients who have low-stage disease. Broader insurance coverage and access to health care may improve some of the disparate outcomes of adolescents and young adults with cancer.

Optimizing fertility preservation practices for adolescent and young adult cancer patients.

Most adolescents and young adults (AYAs) with cancer will survive their disease, and fertility issues are a major concern for this population. The ASCO and new NCCN Clinical Practice Guidelines in Oncology for Adolescent and Young Adult Oncology recommend that oncologists offer the option of fertility preservation to all postpubertal AYAs before the start of potentially gonadotoxic chemotherapy or radiotherapy, providing that the patient does not require emergent start of therapy. Despite the published practice guidelines, many AYAs diagnosed with cancer are still not offered fertility preservation, with oncologists citing lack of time, lack of knowledge, and discomfort in discussing fertility and sexuality with AYAs as reasons. Developing a systematic and coordinated multidisciplinary strategy for fertility preservation referrals within a practice site may streamline the referral process, off-loading some tasks from the oncologist and potentially increasing patient satisfaction, provider satisfaction, and compliance with the guidelines.

Creating a standardized process to offer the standard of care: continuous process improvement methodology is associated with increased rates of sperm cryopreservation among adolescent and young adult males with cancer.

BACKGROUND: There is limited literature on strategies to overcome the barriers to sperm banking among adolescent and young adult (AYA) males with cancer. By standardizing our process for offering sperm banking to AYA males before cancer treatment, we aimed to improve rates of sperm banking at our institution. MATERIALS AND METHODS: Continuous process improvement is a technique that has recently been applied to improve health care delivery. We used continuous process improvement methodologies to create a standard process for fertility preservation for AYA males with cancer at our institution. We compared rates of sperm banking before and after standardization. RESULTS: In the 12-month period after implementation of a standardized process, 90% of patients were offered sperm banking. We demonstrated an 8-fold increase in the proportion of AYA males' sperm banking, and a 5-fold increase in the rate of sperm banking at our institution. DISCUSSION: Implementation of a standardized process for sperm banking for AYA males with cancer was associated with increased rates of sperm banking at our institution. This study supports the role of standardized health care in decreasing barriers to sperm banking.

Ethical Considerations in Balancing Use of Seclusion and Restraint With Risk of COVID-19 Exposure: Recommendations for Youth Inpatient Psychiatry Units.

The onset of the COVID-19 pandemic has presented unique challenges for inpatient psychiatry units (IPUs). IPUs, especially those caring for children and adolescents, rely heavily on milieu group programming to provide care and supervision for patients, and have had to adapt unit policies and procedures to maintain a therapeutic milieu while minimizing COVID-19 transmission.1 Simultaneously providing care while preventing transmission of COVID-19 within IPUs is a formidable task, and many IPUs face the additional challenge of treating youth who have been exposed to, or are actively infected with, COVID-19. In addition, given the need to prevent transmission of COVID-19, recommendations include "mandatory quarantine and isolation when patients refuse to adhere to guidelines,"2 potentially leading to the use of restraint when patients attempt to leave isolation; thus a conflict between the potential risks of enforcing infection prevention policies in order to reduce virus transmission and best practices of eliminating seclusion and restraint (S/R) creates an ethical dilemma for IPUs.

Comparing three methods of assessing peripheral perfusion in critically ill children.

BACKGROUND: Evaluation of peripheral perfusion is a standard practice in pediatric intensive care units (PICUs), which includes the qualitative assessment of foot warmth. The perfusion indicator, derived from the pulse oximetry signal, is available, along with some bedside monitors. OBJECTIVES: To describe the correlation between RN qualitative assessment of foot warmth, measured foot temperature, and perfusion indicator. METHODS: Simultaneous measurements of qualitative foot warmth, measured foot temperature, and perfusion indicator value were obtained on 39 critically ill children ages newborn to 18 years, at least every 2 hours for 48 hours, with 859 measurements completed. RESULTS: There was a positive correlation between all three parameters (p = < 0.0001); however, there was a large amount of variability within groups. CONCLUSION: Qualitative assessment of foot warmth and peripheral perfusion indicator may be helpful in assessing the perfusion in critically ill pediatric patients, but neither is predictably specific as compared to measured foot temperature.

Provider Perspectives on Use of Medical Marijuana in Children With Cancer.

BACKGROUND: Although medical marijuana (MM) may have utility in the supportive care of children with serious illness, it remains controversial. We investigated interdisciplinary provider perspectives on legal MM use in children with cancer. METHODS: We sent a 32-item, cross-sectional survey to 654 pediatric oncology providers in Illinois, Massachusetts, and Washington characterizing MM practices, knowledge, attitudes, and barriers. Forty-eight percent responded; 44% (n = 288) were included in analyses. Providers were stratified by status as legally eligible to certify (ETC) for MM. We used Fisher's exact and Wilcoxon rank tests and univariate and multivariate logistic regression models for group comparisons. RESULTS: The provider median age was 35 years (range 22-70 years); 33% were ETC (83 physicians; 13 Washington state advance practice providers). Thirty percent of providers received ≥1 request for MM in the previous month. Notably, only 5% of all providers knew state-specific regulations. ETC providers were more likely to know that MM is against federal laws (P < .0001). Whereas most providers (92%) reported willingness to help children with cancer access MM, in adjusted models, ETC providers were less likely to indicate approval of patient MM use by smoking, oral formulations, as cancer-directed therapy, or to manage symptoms (P < .005 for all). Forty-six percent of all providers cited the absence of standards around formulations, potency, or dosing to be the greatest barrier to recommending MM. CONCLUSIONS: Most pediatric oncology providers are willing to consider MM use in children with cancer and receive frequent inquiries. However, ETC providers endorse less favorable attitudes overall. The absence of standards is an important barrier to recommending MM.

Recommendations for Premature Ovarian Insufficiency Surveillance for Female Survivors of Childhood, Adolescent, and Young Adult Cancer: A Report From the International Late Effects of Childhood Cancer Guideline Harmonization Group in Collaboration With the PanCareSurFup Consortium.

PURPOSE: Female survivors of childhood, adolescent, and young adult (CAYA) cancer who were treated with alkylating agents and/or radiation, with potential exposure of the ovaries, have an increased risk of premature ovarian insufficiency (POI). Clinical practice guidelines can facilitate these survivors' access to optimal treatment of late effects that may improve health and quality of survival; however, surveillance recommendations vary among the existing long-term follow-up guidelines, which impedes the implementation of screening. PATIENTS AND METHODS: The present guideline was developed by using an evidence-based approach and summarizes harmonized POI surveillance recommendations for female survivors of CAYA cancer who were diagnosed at age < 25 years. The recommendations were formulated by an international multidisciplinary panel and graded according to the strength of the evidence and the potential benefit gained from early detection and intervention. The harmonized POI surveillance recommendations were developed by using a transparent process and are intended to facilitate care for survivors of CAYA cancer. RESULTS AND CONCLUSION: The harmonized set of POI surveillance recommendations is intended to be scientifically rigorous, to positively influence health outcomes, and to facilitate the care for female survivors of CAYA cancer.

Evidence-Based Recommendations for Fertility Preservation Options for Inclusion in Treatment Protocols for Pediatric and Adolescent Patients Diagnosed With Cancer.

As survival rates improve for pediatric cancers, increased attention has been paid to late effects of cancer therapy, in particular, infertility. Fertility preservation options are available for pre- and postpubertal cancer patients; however, many providers lack knowledge regarding options. The aim of this article is to provide a comprehensive synthesis of current evidence and recommendations regarding fertility preservation options for children, adolescents, and young adults undergoing cancer treatment. A systematic search was performed to identify fertility preservation evidence. Fifty-three studies and 4 clinical guidelines were used for the review. Final recommendations consisted of 2 strong and 1 weak recommendation for both female and male fertility preservation options. The treatment team should be knowledgeable about fertility preservation so that they can educate patients and families about available fertility preservation options. It is important to consider and discuss all available fertility options with patients at the time of diagnosis.

Fertility preservation for patients with cancer.

A key concern for young patients with cancer and survivors is the desire to parent a child. With infertility being a well-established long-term effect of many oncologic regimens, patients who want to have children often become distressed when faced with the possibility of losing their fertility. Several organizations have recommended that oncology professionals discuss options for fertility preservation when planning treatment; however, this does not routinely occur. Oncology nurses play a significant role in filling this practice gap by identifying patients who are interested in future parenting and ensuring they get the information and referrals they need to decide whether to pursue fertility preservation. This article outlines the available options, challenges in discussing fertility, and strategies to incorporate fertility education into practice.