Conal Septal Hypoplasia in Tetralogy of Fallot-Impact on Clinical Course, Treatment Strategies, and Outcomes After Surgical Intervention.

We sought to characterize the clinical course and outcomes of intervention for Tetralogy of Fallot (TOF) with associated conal septal hypoplasia (CSH) compared to those with identifiable conal septum on initial newborn echocardiogram. We performed a retrospective, 1:2 case-control study of children with TOF anatomy, 33 with CSH and 66 with typical TOF, who underwent surgical repair from 1991-2019 at Children's Wisconsin. Data on echocardiographic anatomic features, systemic oxygen saturations, medical therapies, admissions, palliative interventions, operative strategies, and long-term follow-up were compared. The CSH group had fewer hypercyanotic spells (6% vs 42%, p < 0.001), beta-blockers prescribed (12% vs 41%, p = 0.005), and hospital admissions for cyanosis (12% vs 44%; p = 0.001) prior to any intervention. Of 14 who required palliative intervention, 8 had balloon pulmonary valvuloplasty (BPV) (7 from the CSH group and 1 from the control group), and 6 had systemic-to-pulmonary artery shunts (all from the control group). Definitive repair was performed at a significantly older age in the CSH group (10.2 ± 10 vs 5.6 ± 5.9 months, p = 0.011), with less subpulmonary muscle resection (57.6% in vs 92.4%, p < 0.001) and higher use of a transannular patch (84.8% vs 65.2%, p = 0.040). The average time to surgical reintervention was similar in both groups (9.7 ± 5.9 vs 8.6 ± 6.4 years in controls). We conclude that infants with TOF and CSH have a milder preoperative clinical course with fewer hypercyanotic spells or need for medical therapy. They also respond well to palliative BPV and can safely undergo later definitive repair compared to typical TOF with a well-developed conal septum.

The Association of Central-Line-Associated Bloodstream Infections With Central-Line Utilization Rate and Maintenance Bundle Compliance Among Types of PICUs.

OBJECTIVE: Central-line-associated bloodstream infections comprise 25% of device-associated infections. Compared with other units, PICUs demonstrate a higher central-line-associated bloodstream infections prevalence. Prior studies have not investigated the association of central-line-associated bloodstream infections prevalence, central-line utilization, or maintenance bundle compliance between specific types of PICUs. DESIGN: This study analyzed monthly aggregate data regarding central-line-associated bloodstream infections prevalence, central-line utilization, and maintenance bundle compliance between three types of PICUs: 1) PICUs that do not care for cardiac patients (PICU); 2) PICUs that provide care for cardiac and noncardiac patients (C/PICU); or 3) designated cardiac ICUs (CICU). SETTING: The included units submitted data as part of The Children's Hospital Association PICU central-line-associated bloodstream infections collaborative from January 1, 2011, to December 31, 2013. PATIENTS: Patients admitted to PICUs in collaborative institutions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The overall central-line-associated bloodstream infections prevalence was low (1.37 central-line-associated bloodstream infections events/1,000 central-line days) and decreased over the time of the study. Central-line-associated bloodstream infections prevalence was not related to the type of PICU although C/PICU tended to have a higher central-line-associated bloodstream infections prevalence (p = 0.055). CICU demonstrated a significantly higher central-line utilization ratio (p < 0.001). However, when examined on a unit level, central-line utilization was not related to the central-line-associated bloodstream infections prevalence. The central-line maintenance bundle compliance rate was not associated with central line-associated bloodstream infections prevalence in this unit-level investigation. Neither utilization rate nor compliance rate changed significantly over time in any of the types of units. CONCLUSIONS: Although this unit-level analysis did not demonstrate an association between central-line-associated bloodstream infections prevalence and central-line utilization and maintenance bundle compliance, optimization of both should continue, further decreasing central-line-associated bloodstream infections prevalence. In addition, investigation of patient-specific factors may aid in further central-line-associated bloodstream infections eradication.

Pediatric Specialty Transport Teams Are Not Associated With Decreased 48-Hour Pediatric Intensive Care Unit Mortality: A Propensity Analysis of the VPS, LLC Database.

OBJECTIVE: The purpose of this study was to determine if pediatric specialty pediatric team (SPT) interfacility-transported children from community emergency departments to a pediatric intensive care unit (PICU) have improved 48-hour mortality. METHODS: This is a multicenter, historic cohort analysis of the VPS, LLC PICU clinical database (VPS, LLC, Los Angeles, CA) for all PICU directly admitted pediatric patients ≤ 18 years of age from January 1, 2007, to March 31, 2009. Categoric variables were analyzed by the chi-square and Mann-Whitney tests for non-normally distributed continuous variables. The propensity score was determined by multiple logistic regression analysis. Nearest neighbor matching developed emergency medical services SPT pairs by similar propensity score. Multiple regression analyses of the matched pairs determined the association of SPT with 48-hour PICU mortality. P values < .05 were considered significant. RESULTS: This study included 3,795 PICU discharges from 12 hospitals. SPT-transported children were more severely ill, younger in age, and more likely to have a respiratory diagnosis (P < .0001). Unadjusted 48-hour PICU mortality was statistically significantly higher for SPT transports (2.04% vs. 0.070%, P = .0028). Multiple regressions adjusted for propensity score, illness severity, and PICU site showed no significant difference in 48-hour PICU mortality. CONCLUSION: No significant difference in adjusted 48-hour PICU mortality for children transported by transport team type was discovered.

Acute Pancreatitis in the Pediatric Intensive Care Unit.

AIM: The aim of this study is to describe the demographics and outcomes of children with a discharge diagnosis of acute pancreatitis (AP) from the pediatric intensive care unit (PICU). METHODS: Data for this retrospective cohort study were obtained from a multisite, clinical PICU database. PICU discharges with a primary or secondary diagnosis of AP (SAP) between 2009 and 2013 from 113 centers were reviewed. We also obtained the Pediatric Index of Mortality 2 Risk of Mortality (PIM2ROM), an indicator of the severity of illness. RESULTS: Of 360,162 PICU discharges, 2026 with a diagnosis of AP were analyzed further (0.56%)-331 had a primary diagnosis of AP, whereas 1695 had a SAP. Among children with primary AP, median PIM2ROM was 1.0% (interquartile range [IQR] 0.8%-1.4%). Fifty-five children with primary AP (16.6%) required mechanical ventilation (MV) for a median of 3.8 days (IQR 1.0-9.3). The length of stay (LOS) in PICU was a median of 2.95 days (IQR 1.53-5.90). Only 1 patient died (mortality 0.3%). Among children with secondary AP, median PIM2ROM was 1.1% (IQR 0.8%-4.0%). A total of 711 children (42.0%) with secondary AP required MV for a median of 5.8 days (IQR 1.8-14.0). PICU LOS was a median of 4.43 days (IQR 1.84-11.22). There were 115 deaths in this group (mortality 6.8%). Median PIM2ROM, PICU LOS, mortality (all P < 0.001), and length of MV (P = 0.035) were significantly greater in children with secondary AP than with primary AP. CONCLUSIONS: Unlike in adult series, children with AP rarely die. Patients with secondary AP experience more morbidity and mortality than patients with primary AP.

Evidence-Based Pediatric Outcome Predictors to Guide the Allocation of Critical Care Resources in a Mass Casualty Event.

OBJECTIVE: ICU resources may be overwhelmed by a mass casualty event, triggering a conversion to Crisis Standards of Care in which critical care support is diverted away from patients least likely to benefit, with the goal of improving population survival. We aimed to devise a Crisis Standards of Care triage allocation scheme specifically for children. DESIGN: A triage scheme is proposed in which patients would be divided into those requiring mechanical ventilation at PICU presentation and those not, and then each group would be evaluated for probability of death and for predicted duration of resource consumption, specifically, duration of PICU length of stay and mechanical ventilation. Children will be excluded from PICU admission if their mortality or resource utilization is predicted to exceed predetermined levels ("high risk"), or if they have a low likelihood of requiring ICU support ("low risk"). Children entered into the Virtual PICU Performance Systems database were employed to develop prediction equations to assign children to the exclusion categories using logistic and linear regression. Machine Learning provided an alternative strategy to develop a triage scheme independent from this process. SETTING: One hundred ten American PICUs SUBJECTS: : One hundred fifty thousand records from the Virtual PICU database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The prediction equations for probability of death had an area under the receiver operating characteristic curve more than 0.87. The prediction equation for belonging to the low-risk category had lower discrimination. R for the prediction equations for PICU length of stay and days of mechanical ventilation ranged from 0.10 to 0.18. Machine learning recommended initially dividing children into those mechanically ventilated versus those not and had strong predictive power for mortality, thus independently verifying the triage sequence and broadly verifying the algorithm. CONCLUSION: An evidence-based predictive tool for children is presented to guide resource allocation during Crisis Standards of Care, potentially improving population outcomes by selecting patients likely to benefit from short-duration ICU interventions.

Incidence and risk factors for venous thromboembolism in critically ill children with cardiac disease.

Cardiac disease is a risk factor for venous thromboembolism (VTE) in children. In this study, we investigated the incidence and risk factors of VTE in critically ill children with cardiac disease, who were prospectively followed-up for VTE after admission to a tertiary care pediatric intensive care unit (PICU). Risk factors were compared between VTE cases and (1) patients in the cohort who did not develop VTE and (2) the next three cardiac patients sequentially admitted to the PICU (case control). Forty-one cases of VTE were identified from 1070 admissions (3.8%). Thirty-seven percent of VTE cases were central venous catheter (CVC)-associated, and 56% of cases were intracardiac. Sixty-six percent of patients were receiving anticoagulation at the time of VTE diagnosis. Increased VTE incidence was associated with unscheduled PICU admission, age <6 months, extracorporeal membrane oxygenation, increased number of CVCs, increased number of CVC days, higher risk of mortality score, and longer PICU stay. Using logistic regression, VTE was associated with single-ventricle physiology (odds ratio [OR] 11.2, 95% CI 3.0-41.9), widened arterial-to-somatic oxygen saturation gradient (SpO(2)-rSO(2) >30) (OR 4.3, 95% CI 1.1-16), and more CVC days (OR 1.1, 95% CI 1.04-1.13). Risk factors for VTE in critically ill children with cardiac disease include younger age, single-ventricle cardiac lesions, increased illness severity, unscheduled PICU admission, and complicated hospital course.

Extended Infusion ß-Lactams for the Treatment of Gram-Negative Bacteremia in Children.

OBJECTIVE: The pharmacokinetics of ß-lactam antibiotics favor administration via an extended infusion. Although literature to support extended infusion ß-lactams exists for adults, few data are available in pediatrics, especially among patients with bacteremia. The purpose of this study was to compare clinical outcomes between extended and standard infusions in children with Gram-negative bacteremia. METHODS: This retrospective chart analysis included hospitalized patients ages 0 to 18 years who received at least 72 hours of cefepime, meropenem, or piperacillin-tazobactam between January 1, 2013 and July 30, 2021. Clinical outcomes included duration of antibiotic therapy, hospital length of stay, readmission within 30 days, all-cause mortality, time to blood culture clearance, and time to normalization of inflammatory markers. RESULTS: A total of 124 patients (51 extended infusion, 73 standard infusion) met criteria for evaluation. Duration of antibiotic therapy was shorter in the extended infusion group (6.6 days versus 10.2 days; p = 0.01). There were no differences in hospital length of stay, readmission rates, all-cause mortality, time to normalization of inflammatory markers, or time to blood culture clearance. CONCLUSIONS: Use of extended infusion ß-lactam antibiotics in children with Gram-negative bacteremia was associated with shorter durations of therapy and should be the preferred method of administration when feasible.

Performance of the Pediatric Index of Mortality 2 for pediatric cardiac surgery patients.

OBJECTIVE: To evaluate the performance of the Pediatric Index of Mortality 2 (PIM-2) for pediatric cardiac surgery patients admitted to the pediatric intensive care unit (PICU). DESIGN: : Retrospective cohort analysis. SETTING: Multi-institutional PICUs. PATIENTS: Children whose PICU admission had an associated cardiac surgical procedure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Performance of the PIM-2 was evaluated with both discrimination and calibration measures. Discrimination was assessed with a receiver operating characteristic curve and associated area under the curve measurement. Calibration was measured across defined groups based on mortality risk, using the Hosmer-Lemeshow goodness-of-fit test. Analyses were performed initially, using the entire cohort, and then based on operative status (perioperative defined as procedure occurring within 24 hrs of PICU admission and preoperative as occurring >24 hrs from the time of PICU admission). A total of 9,208 patients were identified as cardiac surgery patients with 8,391 (91%) considered as perioperative. Average age of the entire cohort was 3.3 yrs (median, 10 mos, 0-18 yrs), although preoperative children tended to be younger (median, <1 month). Preoperative patients also had longer PICU median lengths of stay than perioperative patients (12 days [1-375 days] vs. 3 days [1-369 days], respectively). For the entire cohort, the PIM-2 had fair discrimination power (area under the curve, 0.80; 95% confidence interval, 0.77-0.83) and poor calibration (p < .0001). Its predictive ability was similarly inadequate for quality assessment (standardized mortality ratio, 0.81; 95% confidence interval, 0.72-0.90) with significant overprediction in the highest-decile risk group. For the subpopulations, the model continued to perform poorly with low area under the curves for preoperative patients and poor calibration for both groups. PIM-2 tended to overpredict mortality for perioperative patients and underpredict for preoperative patients (standardized mortality ratios, 0.69 [95% confidence interval, 0.59-0.78] and 1.48 [95% confidence interval, 1.27-1.70], respectively). CONCLUSIONS: The PIM-2 demonstrated poor performance with fair discrimination, poor calibration, and predictive ability for pediatric cardiac surgery population and thus cannot be recommended in its current form as an adequate adjustment tool for quality measurement in this patient group.

Can utilization review criteria be used to determine appropriate pediatric patient placement for a critical care bed expansion?

The rising trend in critical care utilization has led to the expansion of critical care beds in many hospitals across the country. Traditional models of estimating bed capacity requirements use administrative data such as inpatient admissions, length of stay, and case mix index. The use of such data has been limited in quantifying the complexities of demand variables in critical care bed needs. Mathematical modeling is another method for estimating numbers of beds required. It captures the dynamic changes in the management of critically ill patients that occur when units become full. Depending on data analysis methods used, bed need underestimation or overestimation can occur. In our study, we used utilization review criteria to understand changes in level of care (LOC) during the course of patients' stays and to validate critical care bed expansion needs. Using LOC criteria, we studied the proportion of our intermediate care patients in an acute care unit that met acute, intermediate, or critical care criteria. We also evaluated whether these proportions were related to specific factors such as census ratios, staffing proportions, or severity of illness. Using LOC criteria was helpful in validating our critical care bed projection, which was previously derived from mathematical modeling. The findings also validated our assessment for additional specialty acute care beds.

Outcomes Following Surgery to Address Shone Syndrome in Children.

BACKGROUND: Shone syndrome is characterized by coincident mitral valve stenosis and left ventricular outflow tract obstruction. Although first described in 1963, little research has expounded surgical outcomes. We sought to evaluate our experience with this cohort, emphasizing outcomes including mortality, morbidity, and cardiac function. METHODS: A retrospective chart review of 46 patients who underwent operation for Shone syndrome between 1990 and May 2018 was conducted. Index operations included 32 repairs of the left ventricular outflow tract, four mitral valve repair/replacements, nine combined repairs, and one non-Shone's repair. Median age at index procedure was 22 days (2 days-10 years). Mean follow-up was 9.1 years (2 months-21 years), and 70 additional operations (51 reoperations) were required. Three patients were lost to follow-up. RESULTS: Overall survival was 95.7% with two late deaths. Freedom from death or transplant was 93.5%. Thirteen (28.3%) patients remained free from reoperation. Thirty-three patients required 51 reoperations of the left ventricle outflow tract (n = 12), mitral valve (n = 16), combined repairs (n = 21), and transplant (n = 1). At most recent follow-up, patients exhibited mitral stenosis (n = 21), aortic stenosis (n = 7), and diminished LV function (n = 2). CONCLUSION: Surgical correction of Shone's offers excellent survival benefit, but reoperation burden is high, with >70% of patients requiring reintervention in the follow-up period. A total of 65% of patients developed recurrent obstruction of left ventricular inflow or outflow, however, ventricular function is preserved in the majority of patients. All but one patient had no functional deficits, classified as New York Heart Association I with > 60% requiring no medication.

Extended Infusion of Beta-Lactams Is Associated With Improved Outcomes in Pediatric Patients.

OBJECTIVE: The pharmacokinetics of beta-lactam antibiotics favor administration via an extended infusion. Although literature supporting extended infusion beta-lactams exists in adults, few data are available to guide the practice in pediatrics. The purpose of this study was to compare clinical outcomes between extended and standard infusions in children. METHODS: This retrospective chart analysis included hospitalized patients 0 to 18 years old who received at least 72 hours of cefepime, piperacillin-tazobactam, or meropenem between October 1, 2017, and March 31, 2019. Clinical outcomes of care included hospital length of stay, readmission within 30 days, and all-cause mortality. RESULTS: A total of 551 patients (258 extended infusion, 293 standard infusion) met criteria for evaluation. Clinical outcomes among the entire population were similar. A subanalysis of select populations demonstrated decreased mortality in critical care patients (2.1% vs 19.6%, p = 0.006) and decreased 30-day readmission rates in bone marrow transplant patients (0% vs 50%, p = 0.012) who received the extended infusion compared with a standard infusion. CONCLUSIONS: Outcomes were similar between extended and standard infusions in children. Subgroup analyses suggest a possible mortality benefit in the critically ill and decreased readmission rate in bone marrow transplant patients.

Comparison of Patch Materials for Pulmonary Artery Reconstruction.

Various patch materials with variable cost are used for pulmonary artery reconstruction. An analysis of reintervention based on type of patch material might inform value-based decision making. This was a retrospective review of 214 sites of pulmonary artery reconstruction at a single center from 2000 to 2014. We excluded patients with unifocalization of aortopulmonary collaterals. Primary outcome was reintervention for each type of patch. Total number of patch sites was 214 (180 patients). Median follow-up was 3.7 years. Patch materials and number of sites were branch patch homograft (92), bovine pericardium (44), autologous pericardium (41), and porcine intestinal submucosal patch (37). Median age and weight at the time of patch reconstruction were 12.1 months and 8.5 kg. Reintervention occurred at 34 sites (15.9%). With Cox proportional hazards regression, the following variables were associated with reinterevention: preoperative renal failure - hazard ratio of 4.36 (1.87-10.16), P < 0.001 and weight at surgery - hazard ratio 0.93 (0.89-0.98), P = 0.004. Patch type was not related to reintervention (P = 0.197). Cost per unit patch ranged from $0 (dollars, US) for untreated autologous pericardium to $6,105 for homograft branch patch. In this retrospective analysis, there was no relationship between type of patch used for main or central branch pulmonary artery reconstruction and subsequent reintervention on that site. This finding, combined with the widely disparate costs of patches, may help inform value-based decision making.

Early Parenteral Nutrition in Critically Ill Children Not Receiving Early Enteral Nutrition Is Associated With Significantly Higher Mortality.

BACKGROUND: To determine whether early parenteral nutrition (PN) (25% of goal energy within 48 hours of PICU admission) is associated with poorer outcomes in children receiving no enteral nutrition (EN). METHODS: Multicenter retrospective study of patients aged 1 month to 18 years who had a PICU length of stay (PLOS) >96 hours. We obtained weight, sex, pediatric index of mortality 2 score (PIM-2), PLOS, duration of mechanical ventilation (DMV), mortality data, and nutrition intake data. Logistic and mixed model regression analysis were used to compare data. RESULTS: 2069 patients (53.2% male, median age 6.61 years) received no EN in the first 4 days. Children receiving early PN were more likely to die than those who did not when adjusted for PIM-2, propensity score, and center (odds ratio = 2.10 [1.41-3.13], median [IQR]; P = 0.0003). The unadjusted PLOS (9.48 [5.94-18.19], and unadjusted DMV (6.73 [3.48-13.98]) for patients receiving early PN were both significantly longer than those who did not (6.75 [4.95-11.65]; P < 0.0001 and 4.9 [1.88-10.19]; P = 0.009, respectively). When adjusted for PIM-2, center, percentage of energy from protein, and age, the PLOS and DMV for those receiving early PN did not differ from those who did not (P = 0.14 and P = 0.76, respectively). CONCLUSION: In children with PLOS >96 hours receiving no EN for 4 days, early PN is strongly associated with higher mortality but not with differences in PLOS or DMV.

Norwood Procedure-Difficulty in Weaning From Cardiopulmonary Bypass and Implications for Outcomes.

Difficulty weaning from cardiopulmonary bypass (CPB) or the need to return to CPB (collectively D-CPB) may occur after the Norwood procedure. We sought to evaluate the relationship between D-CBP and survival. This was a retrospective chart review of all patients undergoing a Norwood procedure at our institution during the interval 2005-2017. Primary outcome was survival for the Norwood procedure. Secondary outcomes included various measures of morbidity. Successful wean from CBP (S-CPB) was defined as no need to return to full-flow CPB during the initial definitive wean or after separation from CPB; otherwise, the classification was difficulty with wean (D-CBP). Successful rescue in the D-CPB group was defined as not requiring extracorporeal life support either in the operating room or within the first 3 postoperative days. Of the 196 patients in the cohort, 49 were D-CPB. Survival for S-CPB was 92.5% (136/147) vs 71.4% (35/49) for D-CPB (P = 0.001). Major morbidity occurred in 29.9% (44/147) in S-CPB vs 69.4% (34/49) in D-CPB (P < 0.001). With multivariable analysis, D-CPB was significantly associated with mortality (odds ratio = 8.09; confidence interval 2.72-24.05; P < 0.001). Successful rescue occurred in 30 of 49 patients in the D-CPB group and demonstrated survival similar to the S-CPB group. In the Norwood patient, D-CPB is an important intraoperative event and prognostic factor for mortality and morbidity. Successful rescue appears to ameliorate the impact of D-CPB on survival.

Assessment of quality of life in pediatric patients with pulmonary hypertension.

The aim of this study is to evaluate quality of life in four domains (physical, emotional, social, and school) in pediatric patients with pulmonary hypertension (PH) using a validated survey (PedsQL). This is a prospective cohort study of pediatric patients aged 2-18 years with PH. Parents of all children and patients aged 8-18 years with appropriate developmental capacity completed the PedsQL survey in the clinic. Results were compared with published norms for pediatric patients, those with congenital heart disease (CHD) and cancer. Thirty-three children were enrolled yielding 32 parent and 18 patient self-reports: seven patients were aged 2-4 years; three were aged 5-7 years; 11 were aged 8-12 years, and 12 were aged 13-18 years. Twenty-one patients were classified as World Health Organization (WHO) Group I pulmonary arterial hypertension (PAH), 11 WHO Group III PH due to lung disease, and one WHO Group V with segmental PH. Thirteen patients were NYHA functional class (FC) 1, 12 were FC 2, eight were FC 3, and none were FC 4. The PH cohort had significantly lower scores than healthy children in all domains on both parent and self-report. The PH cohort also had significantly lower scores than patients with CHD (parent report: total, physical, social, school; patient self-report: total, physical, school) and cancer (parent report: school; patient self-report: physical, school). Close to 50% of participants reported at risk scores in each domain. The quality of life in pediatric PH patients assessed by PedsQL revealed functional impairment in multiple domains. Administration of the PedsQL during outpatient encounters may provide an easy, reproducible method to assess quality of life and direct referral for interventional services.

Proximal Arch in Left Thoracotomy Repair of Neonatal and Infant Coarctation-How Small Is Too Small?

BACKGROUND: We sought to evaluate the relationship between proximal arch hypoplasia and reintervention for left thoracotomy repair of coarctation of the aorta. METHODS: This was a retrospective review of 153 consecutive neonates and infants undergoing left thoracotomy and extended end-to-end repair of coarctation from January 1, 2000, to January 1, 2014, at a single center with exclusion of single ventricle-palliated patients. Primary outcome was reintervention evaluated with respect to five definitions of proximal arch hypoplasia. RESULTS: Median follow-up was 7.2 years. Reintervention occurred in eight (5.2%) patients, with 50% of patients undergoing re-intervention in the first six months after their index operation. Using Kaplan-Meier analysis and log-rank test, with hypoplasia defined by weight, hypoplasia was not associated with increased reintervention for arch size < patient weight (in kilograms; P = .24) or for arch size < patient weight (in kilograms) +1 (P = .02, higher freedom from reintervention in hypoplasia group). For each of the five comparison groups, freedom from reintervention was similar between the groups with and without proximal arch hypoplasia: (1) z-score < -2 versus ≥-2 (P = .72), (2) z-score < -3 versus ≥-3 (P = .95), and (3) z-score < -4 versus ≥-4 (P = .17). CONCLUSION: In our cohort of patients with left thoracotomy and extended end-to-end repair of coarctation, proximal arch hypoplasia, defined by various weight-based or z-score thresholds, was not associated with reintervention. While this may imply value to a more liberal use of thoracotomy, confirmation requires longer term follow-up with a more comprehensive evaluation of the patients and their arches.

Emergency department revisits for pediatric acute asthma exacerbations: association of factors identified in an emergency department asthma tracking system.

OBJECTIVE: To identify clinical variables associated with a greater likelihood of emergency department (ED) revisit for acute asthma within 7 days after an initial ED visit for acute asthma exacerbation. METHODS: Cross-sectional study of subjects from a prospectively enrolled cohort of children aged 0 to 18 years with physician-diagnosed asthma in the ED Allies Tracking System. Demographics and data on quality of life, health care utilization, environmental factors, chronic asthma severity, and ED management were collected. Emergency department revisits for acute asthma within 7 days of a prior visit resulting in discharge were compared with those without a revisit, using chi2 and t tests and logistic regression. RESULTS: Four thousand two hundred twenty-eight ED asthma visits were enrolled; 3276 visits resulted in discharge. Persistent asthma was identified in 66% of visits. Emergency department revisits within 7 days of a prior visit occurred following 133 (4.1%) visits. There were no significant differences in environmental factors or ED management between visits with and without an ED revisit. In univariate analysis factors associated with a greater revisit likelihood included age younger than 2 years, black race or Hispanic ethnicity, persistent asthma, public insurance, lower quality of life, and greater health care utilization in the prior 12 months. Variables independently significant (P < 0.05) in logistic regression were chronic asthma severity classified as persistent, age younger than 2 years, and lower asthma quality of life. CONCLUSIONS: Although our design precludes drawing causal inference, our results suggest that children younger than 2 years or with persistent asthma or lower asthma quality-of-life scores are at greater risk for ED revisits after acute ED asthma care.

Using Quality Improvement to Change Testing Practices for Community-acquired Pneumonia.

BACKGROUND: National guidelines for pediatric community-acquired pneumonia (CAP) contain recommendations regarding diagnostic testing including chest radiographs (CXRs), complete blood counts (CBCs), and blood cultures. Local data indicated that our institution was not delivering care at standards outlined by these guidelines. This project aimed to decrease CXRs for children with CAP discharged from the emergency department (ED) by 10% and decrease CBCs and blood cultures for patients hospitalized with uncomplicated CAP by 20% within 1 year. METHODS: This single-site quality improvement initiative targeted otherwise healthy children 3 months to 18 years who presented to the ED with uncomplicated CAP at a free-standing academic children's hospital. A quality improvement team performed a series of interventions including guideline implementation, data sharing, and annual education. Process measures included CXR, CBC, and blood culture rates. Balancing measures included the number of patients diagnosed with CAP, the frequency of antibiotic use, length of stay, and ED and hospital return rates. The team used statistical process control charts to plot measures. RESULTS: There was special cause improvement with a desirable downward shift in testing that correlated with the project's interventions. The percentage of CXRs for discharged patients decreased from 79% to 57%. CBCs and blood cultures for hospitalized patients decreased from 30% to 19% and 24% to 14%, respectively. Balancing measures remained unchanged. CONCLUSIONS: We used elements of quality improvement methodology to reduce testing for uncomplicated CAP without impacting the number of patients diagnosed with CAP, the frequency of antibiotic use, length of stay, and reutilization rates.

Early Enteral Nutrition Is Associated With Significantly Lower Hospital Charges in Critically Ill Children.

BACKGROUND: Previous studies have shown that early enteral nutrition (EEN) is associated with lower mortality in critically ill children. The purpose of this study was to determine the association between EEN (provision of 25% of goal calories enterally over the first 48 hours) and pediatric intensive care unit (PICU) and hospital charges in critically ill children. METHODS: We conducted a supplementary study to our previous multicenter retrospective study of nutrition and outcomes in critically ill patients who had a PICU length of stay (LOS) ≥96 hours for the years 2007-2008. From 2 centers, we obtained additional data for all charges incurred during the PICU and hospital stay, respectively, from administrative data sets at each institution. RESULTS: We obtained data for 859 patients who met the inclusion criteria (615 from the first center and 244 from the second center). In the combined data from both centers, total (P = .0006, adjusted for Pediatric Index of Mortality-2 [PIM-2] and center) and daily hospital charges (P < .001, adjusted for PIM-2 and center) were significantly lower in patients who met the EEN goal than in patients who did not. Hospital LOS did not differ between patients who met the EEN goal and patients who did not. A significant interaction between EEN and centers prevented any comparison of PICU charges, daily PICU charges, and PICU LOS between those patients who met the EEN goal and those who did not. CONCLUSION: In critically ill children who stay in the PICU >96 hours, EEN is associated with significantly lower hospital charges.