Applying a Social Ecological Model to Medical Legal Partnerships Practice and Research.

The social ecological model (SEM) is a conceptual framework that recognizes individuals function within multiple interactive systems and contextual environments that influence their health. Medical Legal Partnerships (MLPs) address the social determinants of health through partnerships between health providers and civil legal services. This paper explores how the conceptual framework of SEM can be applied to the MLP model, which also uses a multidimensional approach to address an individual's social determinants of health.

The health law partnership: adding a lawyer to the health care team reduces system costs and improves provider satisfaction.

Addressing the legal issues of patients of low socioeconomic status can be useful in increasing organizational reimbursements, reducing costs and improving access to care. Medical-legal partnership is an addition to the health care armamentarium that directly addresses this goal. A medical-legal partnership is an interdisciplinary collaboration between a medical entity such as a hospital or clinic and a legal entity such as a law school or legal aid society that addresses barriers to access to care and limitations to well-being experienced by patients of low socioeconomic status. The Health Law Partnership is one such medical legal partnership that provides a holistic, interdisciplinary approach to health care. An evaluation of the legal and educational services provided by Health Law Partnership showed that Health Law Partnership secured otherwise unreimbursed Medicaid payments for services over a 4-year period from 2006 to 2010, increased physician satisfaction, and saved hospital employers approximately $10 000 in continuing education costs annually.

Evaluating the Efficacy of Medical-Legal Partnerships that Address Social Determinants of Health.

BACKGROUND: Medical-legal partnerships (MLPs) are health system-community partnerships composed of multi-disciplinary teams designed to improve patient and community health. MLPs provide legal services to address health-harming legal needs that contribute to health inequities. METHODS: A grant provided by the Association of American Medical Colleges (AAMC) and the Centers for Disease Control and Prevention established the Accelerating Health Equity, Advancing through Discovery (AHEAD) Initiative to identify, evaluate, and disseminate community-based interventions that improve health equity. Three geographically and demographically diverse institutions were chosen to strengthen the evidence-base surrounding MLP by developing standardized evaluation tools in the areas of community health, health system savings, and learner outcomes. RESULTS: The generalizable process leading to evaluation tool development is described herein, and includes the formation of multi-institutional teams, logic model development, and stakeholder interviews. CONCLUSIONS: Although MLP is presented, this process can be used by various types of community health partnerships to develop evaluation tools surrounding social determinants of health (SDOH).

Interprofessional Medical-Legal Education of Medical Students: Assessing the Benefits for Addressing Social Determinants of Health.

PROBLEM: Screening tools exist to help identify patient issues related to social determinants of health (SDH), but solutions to many of these problems remain elusive to health care providers as they require legal solutions. Interprofessional medical-legal education is essential to optimizing health care delivery. APPROACH: In 2011, the authors implemented a four-session didactic interprofessional curriculum on medical-legal practice for third-year medical students at Morehouse School of Medicine. This program, also attended by law students, focused on interprofessional collaboration to address client/patient SDH issues and health-harming legal needs. In 2011-2014, the medical students participated in pre- and postintervention surveys designed to determine their awareness of SDH's impact on health as well as their attitudes toward screening for SDH issues and incorporating resources, including a legal resource, to address them. Mean ratings were compared between pre- and postintervention respondent cohorts using independent-sample t tests. OUTCOMES: Of the 222 medical students who participated in the program, 102 (46%) completed the preintervention survey and 100 (45%) completed the postintervention survey. Postintervention survey results indicated that students self-reported an increased likelihood to screen patients for SDH issues and an increased likelihood to refer patients to a legal resource (P < .001). NEXT STEPS: Incorporating interprofessional medical-legal education into undergraduate medical education may result in an increased likelihood to screen patients for SDH and to refer patients with legal needs to a legal resource. In the future, an additional evaluation to assess the curriculum's long-term impact will be administered prior to graduation.

Life-threatening bradyarrhythmia after massive azithromycin overdose.

9-month-old infant was inadvertently administered azithromycin 50 mg/kg, taken from floor stock, instead of the prescribed ceftriaxone. Shortly thereafter, she became unresponsive and pulseless. The initial heart rhythm observed when cardiopulmonary resuscitation was started was a widecomplex bradycardia, with a prolonged rate-corrected QT interval and complete heart block. The baby was resuscitated with epinephrine and atropine, but she suffered severe anoxic encephalopathy. Torsade de pointes and QT-interval prolongation have been reported after administration of macrolide antibiotics, including azithromycin, both intravenously and orally. This has occurred especially in the context of coadministered drugs that inhibit the cytochrome P450 (CYP) 3A4 isoenzyme, such as ketoconazole and astemizole. However, bradycardia with complete heart block has not, to our knowledge, been reported specifically with intravenous administration of azithromycin alone, either with therapeutic doses or overdose. Clinicians should be alerted about the potential of azithromycin to cause life-threatening bradycardia, and pharmacy systems should be implemented to ensure special care in the safe administration of this drug, especially when dispensed from a point-of-care source.

Use of a feeding protocol to improve nutritional support through early, aggressive, enteral nutrition in the pediatric intensive care unit.

OBJECTIVE: To evaluate the effects of instituting a feeding protocol with inclusive bowel regimen on tolerance and time to accomplish goal feeding in the pediatric intensive care unit. DESIGN: Retrospective comparison chart review before and after the initiation of a feeding protocol. PATIENTS: A total of 91 patients in the year 2000, before the initiation of the protocol, who received nasogastric feedings and 93 patients in year 2002 after the protocol was initiated. MEASURES AND MAIN RESULTS: Patients were selected for review if they received nasogastric tube feedings while in the pediatric intensive care unit. The data were reviewed from time of admission in the pediatric intensive care unit through 7 days of goal feedings or discharge from the pediatric intensive care unit. Data examined included: days in the pediatric intensive care unit and hospital, time to goal feedings, concomitant use of cardiovascular medications, sedation, analgesia, episodes of feedings held, vomiting, diarrhea, and constipation. The protocol group achieved goal nutrition in an average of 18.5 hrs and a median of 14 hrs. The retrospective group achieved goal feedings at an average of 57.8 hrs and a median of 32 hrs (p < .0001). Also noted were a reduction in the percentage of patients vomiting from 20% to 11% and a reduction in constipation from 51% to 33%. CONCLUSION: This comparison study suggests that the institution of a feeding protocol will not only achieve goal feedings at a substantially reduced time but also improve tolerance of enteral feedings in patients admitted to the pediatric intensive care unit.

The assessment and management of chronic pain in children.

Chronic pain in children and adolescents is frequently misdiagnosed by caregivers. It is not treated until it results in the loss of routine ability and function. Chronic pain is often associated with underlying diseases commonly seen in childhood, including sickle cell disease, malignancy, rheumatologic disorders, inflammatory bowel disease, trauma, and states where there is no identifiable etiology. Chronic pain differs from acute pain in that it serves no useful function. Untreated or under-treated chronic pain will result in the unnecessary suffering of the patient, disruption of family routine, and cohesiveness and restriction of the child's daily activities, thereby increasing long-term disability. Accurate and repeated assessment of chronic pain is required for therapy to be effective. Assessment of chronic pain in children is difficult due to their developing cognitive abilities. The assessment of childhood pain varies with the child's age, type of pain, situation, and prior painful experiences. Assessment tools such as the Varni-Thompson Pediatric Pain Questionnaire and the Visual Analog Scale are helpful for both the patient and physician in helping to identify situations that precipitate pain, to rate the level of pain and determine if therapy has been effective. Documentation of pain assessments and the effectiveness of interventions in the medical record should be included as a routine part of all patient records. Most caregivers have extensive experience in the treatment of acute pain in children but are often not comfortable with the management of complicated and chronic pain states. The therapy for chronic pain in children is multifactorial. It can include agents from multiple classes of pharmacologic agents (nonsteroidal anti-inflammatory drugs, opioids, tricyclic antidepressants, and antineuroleptics) nonconventional therapies (acupuncture and pressure and aromatherapy), as well as herbal and homeopathic remedies.

Enteral nutrition and cardiovascular medications in the pediatric intensive care unit.

BACKGROUND: Enteral nutrition has multiple benefits for critically ill patients. However, the administration of enteral nutrition to patients requiring medications for cardiovascular support is controversial secondary to concerns of altered splanchnic perfusion. The objective of this study is to evaluate the tolerance of enteral nutrition in pediatric patients receiving cardiovascular medications. METHODS: This was a retrospective chart review of patients admitted to the pediatric intensive care unit at Children's Healthcare of Atlanta at Egleston in a 1-year period. Patients were eligible for the study if they received enteral nutrition during or within 24 hours of requiring continuous infusion of dopamine, dobutamine, epinephrine, norepinephrine, or neosynephrine. RESULTS: Fifty-five admissions (52 patients) met study criteria. Patients ranged in age from 1 month to 20 years old. Although a large number (71%) of patients experienced at least 1 feeding interruption, the majority (70%) of reasons cited for stopping or slowing feedings were not related to gastrointestinal (GI) tolerance. Only 29% of patients had feedings held for perceived intolerance. Vomiting was the most often-cited reason for these interruptions. Constipation was reported in 36% of patients but cited only 4 times as a reason for feeding interruption. Four patients exhibited evidence of GI bleeding. This bleeding was considered clinically insignificant in 2 patients and appeared unrelated to enteral feedings in the others. CONCLUSIONS: This study suggests that many pediatric patients receiving cardiovascular medications tolerate enteral nutrition without adverse events. Further prospective studies are needed to determine whether enteral nutrition can consistently benefit these critically ill pediatric patients.

Hair loss after extracorporeal membrane oxygenation.

OBJECTIVE: To discuss the factors associated with hair loss reported after the completion of extracorporeal membrane oxygenation. DESIGN: Prospective survey and retrospective chart review. SETTING: Tertiary care pediatric and adult extracorporeal membrane oxygenation program in a children's hospital. PATIENTS: All patients aged > or =60 months who underwent extracorporeal membrane oxygenation for respiratory or cardiac failure. INTERVENTIONS: Telephone survey of all patients or patient families who met study entry criteria. MEASUREMENTS AND MAIN RESULTS: Twelve extracorporeal membrane oxygenation patients met entry criteria. Nine were contacted and surveyed. Seven children and one adult reported hair loss. One child had no reported hair loss. One patient had a reported hair loss of <10%, three had 25% hair loss, two had 50% hair loss, and two had >50% hair loss. Initial hair loss occurred between 2 wks and 3 months after extracorporeal membrane oxygenation and lasted from 1 to 6 months. No patient sought medical treatment and all reported regrowth of their hair by 6 months after identifying the initial hair loss. CONCLUSIONS: Hair loss after critical illness is a well-documented phenomenon. Hair loss after extracorporeal membrane oxygenation has not been previously reported. The etiology of the hair loss is probably multifactorial and resolves spontaneously. Patients and families should be educated about hair loss as a potential side effect of extracorporeal membrane oxygenation during their post-extracorporeal membrane oxygenation and discharge teaching.

Primary use of the venovenous approach for extracorporeal membrane oxygenation in pediatric acute respiratory failure.

OBJECTIVES: To describe a single center's experience with the primary use of venovenous cannulation for supporting pediatric acute respiratory failure patients with extracorporeal membrane oxygenation (ECMO). DESIGN: Retrospective chart review of all patients receiving extracorporeal life support at a single institution. SETTING: Pediatric intensive care unit at a tertiary care children's hospital. PATIENTS: Eighty-two patients between the ages of 2 wks and 18 yrs with severe acute respiratory failure. INTERVENTIONS: ECMO for acute respiratory failure. MEASUREMENTS AND MAIN RESULTS: From January 1991 until April 2002, 82 pediatric patients with acute respiratory failure were cannulated for ECMO support. Median duration of ventilation before ECMO was 5 days (range, 1-17 days). Sixty-eight of these patients (82%) initially were placed on venovenous ECMO. Fourteen patients were initiated and remained on venoarterial support, including six in whom venovenous cannulae could not be placed. One patient was converted from venovenous to venoarterial support due to inadequate oxygenation. Venoarterial patients had significantly greater alveolar-arterial oxygen gradients and lower PaO(2)/FIO(2) ratios than venovenous patients (p <.03). Fifty-five of 81 venovenous patients received additional drainage cannulae (46 of 55 with an internal jugular cephalad catheter). Thirty-five percent of venovenous patients and 36% of venoarterial patients required at least one vasopressor infusion at time of cannulation (p = nonsignificant); vasopressor dependence decreased over the course of ECMO in both groups. Median duration on venovenous ECMO for acute hypoxemic respiratory failure was 218 hrs (range, 24-921). Venovenous ECMO survivors remained cannulated for significantly shorter time than nonsurvivors did (median, 212 vs. 350 hrs; p =.04). Sixty-three of 82 ECMO (77%) patients survived to discharge-56 of 68 venovenous ECMO (81%) and nine of 14 venoarterial ECMO (64%). CONCLUSIONS: Venovenous ECMO can effectively provide adequate oxygenation for pediatric patients with severe acute respiratory failure receiving ECMO support. Additional cannulae placed at the initiation of venovenous ECMO could be beneficial in achieving flow rates necessary for adequate oxygenation and lung rest.

Can access to a medical-legal partnership benefit patients with asthma who live in an urban community?

Approximately one in 10 children in the U.S. has a diagnosis of asthma. African American and low-income children are more likely to be diagnosed with asthma. They are more likely to suffer the worse outcomes because of low socioeconomic status and environmental exposures. A medical-legal partnership is an interdisciplinary collaboration between a medical entity such as a hospital or clinic and a legal entity such as a lawyer, law school, or legal aid society created to address barriers to health care access and limitations to well-being. Addressing the legal concerns of these patients can improve access to medical services, reduce family stress, and address legal concerns that contribute to poor health. The Health Law Partnership (HeLP) is one such medical-legal partnership that provides a holistic, interdisciplinary approach to health care. During the seven-year study period we found both financial ($501,209) and non-financial benefits attributable to interventions by the attorneys at HeLP.

Medical-legal partnership: impact on patients with sickle cell disease.

OBJECTIVE: To determine the types of legal problems addressed by the Health Law Partnership (HeLP) and the impact of the legal interventions in pediatric patients with sickle cell disease (SCD) or its variants. We hypothesized that an interdisciplinary team that includes lawyers would positively affect the social determinants of health that affect patients with SCD. METHODS: The HeLP database was retrospectively queried for all patients with the diagnosis of SCD or 1 of its variants who had been seen by the lawyers of HeLP between April 2004 and September 2010. Data collected in this cohort of patients included income level of the patient/client, the initial presenting problems, any patient/parent/guardian problems identified during the legal checkup, and the type of legal assistance provided. Estimated annualized financial outcomes were calculated. RESULTS: From April 2004 through September 2010, 71 parents/guardians with 76 children with SCD were referred to the HeLP for legal intervention. Of the 71 parents/guardians, 33 were at <100% of the federal poverty level. There were 106 initial case problems identified in the 71 parents/guardians; 51 of 106 problems were directly related to the child. An additional 93 issues were identified during the legal checkup. Of 106 cases, 99 were closed with 21 resulting in a measurable gain of benefits. CONCLUSIONS: In a cohort of families of children with SCD, incorporating access to legal services as part of the care plan resulted in a positive impact on these patients/parents/guardians. The impact was directly attributable to the intervention of the HeLP.

Halothane, an effective infrequently used drug, in the treatment of pediatric status asthmaticus: a case report.

Asthma is the most common chronic disease of childhood. Despite a better understanding of the disease process and its management, status asthmaticus continues to be a life-threatening event. The use of volatile inhaled anesthetics is infrequently reported as adjunctive therapy to conventional treatment of this condition. We report the use of halothane in a mechanically ventilated pediatric patient with life-threatening status asthmaticus who was admitted to the pediatric intensive care unit (PICU) after failing to respond to standard medical therapy and noninvasive positive pressure ventilation. A 12-year-old African American male was seen in the emergency department and treated with intravenous corticosteroids, beta-agonist therapy. He deteriorated rapidly and required endotracheal intubation and mechanical ventilation. Two hours later, the patient developed an acute, severe respiratory acidosis (pH=6.97, PaCO2=171, PaO2=162, BE=1.7). Halothane was started at 2% by using the Siemens Servo 900C anesthesia ventilator. Improvement in both arterial blood gases and exhaled tidal volume were noted 30 minutes after initiation of the anesthetic gas. The patient remained on halothane for a total of 36 hours. No adverse effects associated with the use of halothane were noted. The patient was extubated to BiPAP 16/6, FiO2=0.30 at 68 hours and was discharged home 5 days later.

Systemic hypertension associated with venovenous extracorporeal membrane oxygenation for pediatric respiratory failure.

BACKGROUND/PURPOSE: Arterial hypertension (HTN) is common in neonates on venoarterial (VA) extracorporeal membrane oxygenation (ECMO), but HTN in pediatric venovenous (VV) ECMO has not been well described. The authors noted HTN in their VV ECMO experience and hypothesized that HTN was associated with fluid status, steroid use, and renal insufficiency. METHODS: Records of 50 patients receiving VV ECMO for respiratory failure were reviewed. HTN was defined as systolic blood pressure greater than 95th percentile for age for > or =1 hour, unresponsive to sedation/analgesia. Hypertensive index (HI) is defined as total hypertensive hours per total ECMO hours. Fluid status was estimated by a fluid index (FI = total fluid balance during ECMO per ECMO hours per weight). RESULTS: Forty-seven of 50 patients (94%) had HTN. Median HI was 0.21 (range, 0.01 to 1.0). Thirteen patients had renal insufficiency, 39 received steroids, and 23 received continuous venovenous hemofiltration (CVVH). There was no association between HI and FI, steroid use, or renal insufficiency. Thirty-three patients were treated for HTN, often requiring multiple agents. Bleeding complicated the course of 18 patients, and HI was significantly higher in those patients (P = .03). HI was not different between survivors (37 of 39 with HTN) and nonsurvivors (10 of 11 with HTN). CONCLUSIONS: Hypertension is a common complication associated with VV ECMO with unclear etiology. HTN was frequently difficult to control. This study emphasizes the need for the development of treatment protocols to decrease the incidence, severity, and associated morbidity. Improved insight into the etiology of HTN associated with pediatric VV ECMO, including evaluation of the renin-angiotensin system, would help guide therapy.