Variation in Length of Stay by Level of Neonatal Care Among Moderate and Late Preterm Infants.

BACKGROUND AND OBJECTIVES: Moderate and late preterm infants are a growing subgroup of neonates with increased care needs after birth, yet standard protocols are lacking. We aim to describe variation in length of stay (LOS) by gestational age (GA) across hospitals within the same level of neonatal care and between different levels of neonatal care. METHODS: Retrospective cohort study of hospitalizations for moderate (32-33 weeks GA) and late (34-36 weeks GA) preterm infants in 2019 Kid's Inpatient Database. We compared adjusted LOS in this cohort and evaluated variation within hospitals of the same level and across different levels of neonatal care. RESULTS: This study includes 217 051 moderate (26.2%) and late (73.8%) preterm infants from level II (19.7%), III (66.3%), and IV (11.1%) hospitals. Patient-level (race and ethnicity, primary payor, delivery type, multiple gestation, birth weight) and hospital-level (birth region, level of neonatal care) factors were significantly associated with LOS. Adjusted mean LOS varied for hospitals within the same level of neonatal care with level II hospitals showing the greatest variability among 34- to 36- week GA infants when compared with level III and IV hospitals (P < .01). LOS also varied significantly between levels of neonatal care with the greatest variation (0.9 days) seen in 32-week GA between level III and level IV hospitals. CONCLUSIONS: For moderate and late preterm infants, the level of neonatal care was associated with variation in LOS after adjusting for clinical severity. Hospitals providing level II neonatal care showed the greatest variation and may provide an opportunity to standardize care.

Pediatric Hospitalist Resuscitation Skills Refresher Training With Pauses for Deliberate Practice.

Introduction Pediatric hospitalists are expected to lead resuscitative efforts for cardiopulmonary arrests, but the infrequency of these events and pediatric advanced life support (PALS) re-certifications are insufficient to maintain skill proficiency.We created a novel resuscitation refresher curriculum for pediatric hospitalists with strategic pauses during simulations for expert and peer coaching of procedural skills. Methods In a tertiary care academic pediatric hospital between September 2018 to June 2019, pediatric hospitalists and fellows voluntarily participated in a series of three quarterly two-hour training sessions taught by expert peer facilitators. Sessions focused on the thirty-second rapid cardiopulmonary assessment and each of the pediatric advanced life support (PALS) algorithms. Scenarios were strategically paused to practice critical hands-on skills. Cases centered on the themes of shock, respiratory, and cardiac emergencies and took place in a high-fidelity simulation lab requiring a technician and expert peer facilitator. Participants anonymously completed Likert scale-based evaluations after each session and again at the end of the year that focused on participants' own perceived change in their comfort levels in performing various resuscitation skills and in knowing basic resuscitation steps. As part of our institutional and personal assessment of the curriculum, an end-of-year survey additionally asked participants to reflect on the overall simulation curriculum and resultant changes in their clinical practice. Results Comfort in all skills practiced across the three sessions increased. The end-of-year survey showed a significant rise in comfort above baseline but some decrements when compared to that immediately post-training. Ninety-six percent of pediatric hospitalists rated the overall quality of the training "better" or "much better" than other resuscitation training (including PALS classes and traditional simulations with skills training after the scenario). The overall effect of the curriculum on perceived knowledge, skills, and confidence levels was significant (p <0.0001). Conclusion Serial resuscitation skills refreshers with expert peer coaching and strategic pauses for hands-on skills practice can result in significant improvements in perceived knowledge and comfort with skill performance as well as the leadership role among pediatric hospitalists.

Strategies for Teaching Medical Students: A Faculty Development Workshop for Pediatric Preceptors in the Community Setting.

Introduction: An increasing number of medical students complete clerkships outside of traditional university-affiliated medical centers despite little faculty development geared specifically for the community preceptor. Moreover, the community setting presents a unique set of challenges, including fewer educational resources, greater expectation of clinical productivity, and a wide geographic distribution of preceptors. Methods: This 90-minute workshop provided pediatric community preceptors with effective teaching strategies that could be used in their setting. First, participants identified opportunities and challenges for medical student education in the community setting. Then, participants discussed approaches to strengthen the students' learning experience in small-group breakout sessions. Finally, workshop leaders emphasized specific teaching resources and methods to empower participants. Results: This workshop was presented at three national pediatric conferences and had at least 57 participants (40 total respondents). Over the three iterations, participants consistently rated this workshop as highly effective and engaging, with the small-group breakout session rated most engaging. Over time, modifications to the workshop included lengthening breakout sessions, shortening didactic materials to enhance audience discussion, and expanding content to include the outpatient setting. In later iterations, participants identified a specific medical education challenge at their institution and committed to using a technique they learned from the workshop. Discussion: This workshop targeted inpatient and outpatient pediatric preceptors to address the community-based faculty development gap. After completing the workshop, community preceptors can enhance the medical education experience by optimizing invaluable opportunities in the community setting and applying targeted strategies and resources.

Human fetal membrane expression of IL-19 and IL-20 and its differential effect on inflammatory cytokine production.

Objective. The objectives of this study were to document the expression of IL-19 and IL-20, localize their expression in human fetal membranes and to examine their influence on the production of other inflammatory cytokines (IL-1, IL-6, IL-8, and TNF-alpha) from placental membranes.Methods. Human fetal membranes collected at term from normal pregnancies were stimulated with either recombinant human IL-19, IL-20, bacterial endotoxin (LPS) alone or the cytokine + LPS. The expression of IL-19 and IL-20 was studied by reverse transcriptase polymerase chain reaction (RT-PCR) and localized using immunohistochemistry. Concentrations of IL-1, IL-6, IL-8, and TNF-alpha were measured with multiplex sandwich immunoassay using microsphere technology.Results. RT-PCR documented IL-19 and IL-20 gene expression in fetal membranes. Immunohistochemistry localized both peptides to amnion and chorion layers. LPS stimulated the production of all four cytokines (IL-1, IL-6, IL-8, and TNF-alpha) from fetal membranes compared to unstimulated controls. No change in IL-1 and IL-8 concentration was seen after IL-19 or IL-20 stimulation, whereas IL-6 concentration was three- and two-fold higher after IL-19 and IL-20 treatment, respectively. TNF levels were unchanged after IL-19 and IL-20 treatment; however, TNF levels were significantly decreased in membranes treated with IL-19 or IL-20 + LPS compared to LPS alone.Conclusion. Fetal membranes are a source of IL-19 and IL-20. These cytokines act as an inhibitory agent to LPS-induced TNF production whereas they stimulate IL-6 production and have no effect on IL-1 and IL-8 production from human fetal membranes. The effect of IL-19 and IL-20 in pregnancy will be dependent on their concentrations and other environmental factors such as infection.

Pediatric Medication Safety in Adult Community Hospital Settings: A Glimpse Into Nationwide Practice.

BACKGROUND AND OBJECTIVES: Most children in the United States are treated in adult settings. Studies show that the pediatric population is vulnerable to medication errors. It can be extrapolated that children cared for in adult settings are at equal or higher risk for errors. The goal of this study was to assess the existing pediatric medication safety infrastructure within adult hospitals. METHODS: Questionnaire developed through Research Electronic Data Capture (REDCap) and distributed to pediatric hospitalist programs listed on the American Academy of Pediatrics, Section on Hospital Medicine web site and members of the American Academy of Pediatrics Quality Improvement Innovation Networks listserv. There were >20 questions regarding the use of various safety measures and characteristics of the hospital. RESULTS: Thirty-eight program staff and 26 Quality Improvement Innovation Networks listserv members completed the survey (total = 64). Of these, 90.6% use order sets or computerized provider order entry with pediatric weight-based dosing, 79.7% review pediatric medication safety events or concerns, 58.7% were aware that their hospital had defined or documented maximum doses on orders, and 50.0% had milligram-per-kilogram dosing required to be in the order. A majority of respondents document weights only in the metric system (kilograms or grams) in both the emergency department and the pediatric unit (84.4% and 92.1%, respectively). A total of 57.8% of hospitals had pharmacists trained in pediatrics, with hospitals with >300 beds more likely to have a pediatric pharmacist than those with <300 beds (75% vs 44%, P ≤ .05). CONCLUSIONS: Pediatric medication safety infrastructure shows variations within the sites surveyed. Our results indicate that certain deficiencies are more widespread than others, providing opportunities for targeted, but hospital-specific interventions.