Comanagement of Surgical Pediatric Patients in the Acute Care Inpatient Setting.

The care of children with primary surgical diagnoses in acute care units often involves a shared surgical and medical model ("comanagement"). There are no formal guidelines for how such programs should be structured or care provided. We used a modified Delphi process, including national experts in pediatrics and pediatric medical subspecialties, pediatric surgical specialties, and pediatric anesthesiology, to develop recommendations for best practices for comanagement programs in community and tertiary care settings.

Prevalence and risk factors in postoperative pancreatitis after spine fusion in patients with cerebral palsy.

BACKGROUND: Postoperative pancreatitis is a recognized complication after spine fusion surgery in scoliosis management. There are established risk factors for the development of postoperative pancreatitis for patients with scoliosis in general, but no such factors have been established in patients with cerebral palsy (CP) who have scoliosis. The aim of this study was to assess the association between preoperative comorbidities and other parameters in the development of pancreatitis after spinal fusion surgery in a sample of children with CP. METHODS: A retrospective cohort design was used to assess the association between postoperative pancreatitis and preoperative comorbidities and other covariates that might predispose to pancreatitis. The study participants included 355 patients, with a mean age of 13.8 years (range, 5.6-21 years) with CP, who received spine fusion with rod instrumentation. We used the chi statistic, mean, and SD to describe study variables that were categorical and continuous, respectively. To test the null hypothesis of no association between our outcome variable (postoperative pancreatitis) and comorbidities and other covariates as predictors, we used a binomial regression model. To simultaneously adjust for confounding effects in the relationship between our outcome and the independent or predictor variables, we used a multivariable binomial regression model. RESULTS: Of the 355 patients who underwent spine fusion, 109 developed postoperative pancreatitis (prevalence, 30.1%). Patients who developed pancreatitis had prolonged number of fasting days (until oral or G-tube feeding initiated; 7.9 vs 5.2 days) and longer hospital stay (23.1 vs 15.6 days). In the univariable binomial regression model, patients with CP who had gastroesophageal reflux disease (GERD) and feeding difficulty were more likely to develop pancreatitis than those without this condition (risk ratio [RR], 1.57; 95% confidence interval [CI], 1.10-2.28, respectively). Likewise, in this model, gastrointestinal tube and reactive airway disease (RAD) were statistically significantly associated with postoperative pancreatitis. Patients with CP who had gastrointestinal tube were 61% more likely to develop postoperative pancreatitis, whereas those with RAD were 54% (RR, 1.61; 95% CI, 1.01-2.55 and RR, 1.54; 95% CI, 1.13-2.10, respectively). However, there was a clinically relevant but nonstatistically significant association between seizure and postoperative pancreatitis (RR, 1.72; 95% CI, 0.96-3.06). After adjustment for the confounding variables in the multivariable model, GERD with feeding difficulties persisted as a single most significant and potent predictor of postoperative pancreatitis (adjusted RR, 1.52; 95% CI, 1.01-2.29). Consequently, patients with CP who had GERD were 52% more likely to develop postoperative pancreatitis. Likewise, there was a statistically significant 49% increase in the risk of postoperative pancreatitis in patients with CP who had RAD (adjusted RR, 1.49; 95% CI, 1.10-2.04). CONCLUSIONS: Pancreatitis is a major cause of morbidity after spinal fusion surgery in patients with CP. Patients with preoperative GERD with feeding difficulties and RAD had a higher risk of developing postoperative pancreatitis. Postoperative pancreatitis causes delays in feeding and increases the duration of hospitalization. Clinicians should be aware of the roles of GERD and RAD, as well as seizure and/or antiepileptics in the development of postoperative pancreatitis in patients with CP undergoing spinal fusion. LEVEL OF EVIDENCE: Level III.

Pediatric hospitalist comanagement of surgical patients: challenges and opportunities.

Hospitalists are increasingly providing comanagement of surgical patients. Limited data published regarding hospitalist comanagement of adult surgical patients have suggested that these partnerships may help improve outcomes and limit resource usage. Pediatric surgical comanagement programs at community hospitals will face different clinical challenges than those at tertiary referral pediatric centers. Pediatric hospitalists providing surgical comanagement must also address specific administrative issues including program structure, communication, staffing, and finances.

Nurses' assessment of pediatric physicians: are hospitalists different?

The interaction between physicians and nurses represents a critical aspect of patient care. The numbers and influence of hospitalists-physicians who provide care to hospitalized patients-continue to increase. However, studies of interactions between nurses and hospitalists are limited. As a bridge to that gap, we studied pediatric nurses' assessment of pediatric hospitalists along with other categories of pediatric physicians (e.g., residents, surgeons) in terms of these physicians' interactions with nurses and patients and the quality of care they provide. Pediatric nurses at a tertiary children's hospital were invited to complete an anonymous online survey. They were asked to rate different categories of physicians according to various qualities of the nurse-physician relationship and patient care. Nurses were also given an opportunity to provide feedback regarding pediatric hospitalists' role in comanaging medically complex surgical patients. Our findings indicate that nurses ranked pediatric hospitalists and residents at the top in terms of nurse-physician interaction. In addition, nurses rated pediatric hospitalists highest for patient care qualities and indicated their overwhelming preference for hospitalists to comanage medically complex surgical patients. As our findings suggest, nurses may interact differently with hospitalists than with other types of physicians. As hospitalists become more influential in U.S. hospitals, it is important that positive relationships are carefully developed between nurses and hospitalists. Hospitalist programs may be key to improving the nursing practice environment and may lead to the retention of nurses.

Hospitalists in medical education: coming to an academic medical center near you.

Hospitalists are physicians whose medical practice focuses on general medical inpatient care. In the past decade, the number of practicing hospitalists has soared, and hospitalist programs have been established at both community hospitals and academic medical centers. As hospitalists increasingly assume a greater share of inpatient care responsibilities, they will contribute to the training of medical students and house staff. This paper reviews current data on the impact of hospitalists on medical education and the future of hospitalist training.

Culture Pus, Not Blood: Decreasing Routine Laboratory Testing in Patients With Uncomplicated Skin and Soft Tissue Infections.

BACKGROUND: Blood cultures and complete blood cell counts (CBCs) are commonly used in evaluating patients with skin and soft tissue infections (SSTIs). Published data have shown that these tests may not aid in patient management. The objective of this study was to decrease the collection of blood test specimens in children with uncomplicated SSTIs. METHODS: We designed a longitudinal preintervention/postintervention study that used modifications of well-known propaganda posters. These were displayed in work stations to discourage staff from ordering routine blood cultures in children being evaluated for uncomplicated SSTIs. We studied a total of 230 otherwise healthy patients with SSTIs admitted to a freestanding children's hospital between September 1, 2013, and August 31, 2014. Data were collected in 3 groups: a 4-month baseline period, a 4-month poster display period, and a 4-month follow-up period to determine practice change persistence. Data collected included baseline clinical characteristics, the number of laboratory studies obtained, and outcomes (including length of stay). RESULTS: Patients in the 3 groups were similar in terms of clinical characteristics. Compared with baseline, posters were associated with decreased blood cultures (47%-17%; P < .001) and CBCs (53%-36%; P = .04). This effect partially persisted for results of blood cultures (27%; P = .01) and CBCs (42%, P = .17). There was no change in median length of stay. Seven-day emergency department returns increased in the poster group (0-7%; P = .02) with no clear relation to laboratory testing, but not in the follow-up group (3%; P = .15). CONCLUSIONS: A simple and creative poster campaign improved staff laboratory testing practices.

Nuremberg and Tuskegee: lessons for contemporary American medicine.

The activities of German doctors during the Nazi regime are well known and documented. They include efforts at eugenic sterilization and euthanasia, gruesome medical experimentation, and contributions to genocide. The German medical profession embraced the Nazi ideology of racial superiority. Nazi doctors enthusiastically perverted traditional medical mores of viewing each patient as a full individual towards a misguided sense of protecting the racial well-being of the nation from the perceived threat of certain groups of people. Similarly, some 20th-century American physicians engaged in activities prompted by a misguided sense of patients' worth as individuals. This essay will examine the ethical problems of Nazi medicine and ethical missteps in the United States in the context of challenges for contemporary physicians, particularly the way in which we refer to our patients.

Pediatric hospitalist preoperative evaluation of children with neuromuscular scoliosis.

WHAT'S NEW: This is the first study of a pediatric hospitalist preoperative clinic. Pediatric hospitalists frequently make significant recommendations for patients with neuromuscular scoliosis prior to spinal surgery, especially those with medical complexity. Certain clinical criteria are statistically significantly associated with a hospitalist making a preoperative recommendation. OBJECTIVE: To assess (1) how frequently pediatric hospitalists make recommendations when evaluating preoperative neuromuscular scoliosis patients in anticipation of spinal fusion surgery and (2) evaluate if any clinical characteristics are associated with a higher likelihood of hospitalists doing so. METHODS: We performed a case series study using retrospective chart review of 214 patients scheduled for spinal fusion surgery for neuromuscular scoliosis from November 2009 through September 2012. RESULTS: We analyzed data for 214 patients aged 1 to 20 years (median, 13 years), of whom 155 (72%) received at least 1 specific preoperative recommendation, whereas 59 patients (28%) were cleared for surgery without specific recommendations. Underlying diagnosis (P = 0.024), nonambulatory status (odds ratio [OR]: 2.02, 95% confidence interval [CI]: 1.09-3.74), and increased number of preoperative medications (OR: 1.19, 95% CI: 1.06-1.34) were statistically significantly associated with an increased rate of receiving preoperative recommendations from the hospitalist. Comorbidities such as seizure disorder (OR: 2.68, 95% CI: 1.29-5.57) and gastrointestinal conditions (OR: 3.35, 95% CI: 1.74-6.45) were also statistically significantly associated with specific presurgical recommendations being made by the pediatric hospitalist. CONCLUSION: A pediatric hospitalist preoperative program for children with neuromuscular scoliosis in anticipation of spinal fusion surgery is associated with a high rate of recommendations being made, especially in children with certain clinical characteristics.

Outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery.

OBJECTIVE: The goal of this study was to assess outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis. METHODS: A hospitalist comanagement program was implemented at a children's hospital. We conducted a retrospective case series study of patients during 2003-2008 to compare clinical and cost outcomes for 87 preimplementation patients, 40 patients during a partially implemented program, and 80 patients during a fully implemented program. RESULTS: When compared with preimplementation patients, full implementation program patients did not demonstrate a statistically significant difference in median length of stay on the medical/surgical unit after transfer from the PICU (median: 6 vs 8 days; P = .07). Patients in the full implementation group received fewer days of parenteral nutrition (median: 0 vs 6 days; P = .0006) and had fewer planned and unplanned laboratory studies on the inpatient unit. There was no statistically significant change in returns to the operating room (P = .08 between preimplementation and full implementation), other complications, or 30-day readmissions. Median hospital costs increased from preimplementation ($59372) to partial implementation ($89302) and remained elevated during full implementation ($81 651) compared with preimplementation (P = .004). Mean physician costs followed a similar trajectory from preimplementation ($18425) to partial implementation ($24101) to full implementation ($22578; P = .0006 [versus preimplementation]). CONCLUSIONS: A hospitalist comanagement program can significantly affect the care of medically complex children undergoing spinal fusion surgery. Initial program costs may increase.

Electrical activity and exocytotic correlates of biphasic insulin secretion from beta-cells of canine islets of Langerhans: contribution of tuning two modes of Ca2+ entry-dependent exocytosis to two modes of glucose-induced electrical activity.

Biphasic insulin secretion in response to glucose, consisting of a transient first phase followed by a progressive second phase, is well described in pancreatic islets. Using single canine beta-cells we have compared the time courses of electrical activity and insulin granule exocytosis to biphasic insulin secretion. Short trains of action potentials, similar those found during first phase insulin secretion, trigger phasic exocytosis from a small pool of insulin granules, likely an immediately releasable pool docked near voltage activated Ca(2+) channels. In contrast, plateau depolarizations to between -35 and -20 mV resembling those during second phase insulin secretion, trigger tonic exocytosis from a larger pool of insulin granules, likely a highly Ca(2+)-sensitive pool farther from Ca(2+) channels. Both phasic and tonic modes of exocytosis are enhanced by glucose, via its metabolism. Hence, in canine beta-cells two distinct components of exocytosis, tuned to two components of electrical activity, may contribute significantly to biphasic insulin secretion.