Adolescent Drug Ingestions Requiring ICU Stay: Single-Center Retrospective Cohort Study.

OBJECTIVES: Ingestions are a prevalent form of self-harm in teenagers and are unfortunately an increasingly common reason for admission to both acute care and critical care services. The goal of this study was to identify characteristics associated with requiring PICU stay among adolescents hospitalized for ingestions. DESIGN: Retrospective cohort study comparing patients admitted to hospital medicine service and critical care service from January 2019 to December 2019. SETTING: Freestanding children's hospital in the midwestern United States. PATIENTS: Adolescents 12-18 years old hospitalized for ingestion. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Out of 209 patients included in the study cohort, 95 required PICU admission. High-risk behaviors (having had sex or usage of alcohol, drugs, tobacco, or vaping) were endorsed by 190 of 209 patients (91%). We compared patient characteristics, ingestion history, workup, and pharmacological and PICU-specific interventions between patients hospitalized on the hospital medicine service and the PICU. We failed to identify an association between reason for ingestion, substance ingested, and previously identified suicide risk factors including previous suicide attempt, previous self-harm, and psychiatric comorbidity and admission to PICU, as opposed to non-PICU admission. PICU stay was associated with longer peak corrected QT interval value, receiving a pharmacological intervention, and longer duration of hospital stay. Fifteen of 95 patients (16% [95% CI, 9-25%]) in the PICU received a PICU-specific intervention. CONCLUSIONS: We failed to identify specific patient demographics or mental behavioral health characteristics associated with PICU stay after ingestion. Therefore, we believe that all adolescents hospitalized due to ingestion-irrespective of disposition-should receive standardized high-risk behavior screening due to the pervasive nature of these behaviors among this patient population. PICU-specific care, beyond observation, could be needed in as high as one-in-four PICU admissions. Further research is needed to inform optimal disposition and resource allocation for this patient population.

Severe methemoglobinemia due to topical dapsone misuse in a teenage girl.

Dapsone gel is a topical treatment for facial acne in adolescents and adults, and while systemic dapsone therapy is known to be associated with methemoglobinemia, once-daily topical dapsone has been well tolerated with few side effects in large randomized controlled trials. We describe the first reported case of severe methemoglobinemia in a healthy adolescent using daily topical dapsone. Although the medication was prescribed for facial use only, the patient reported topical use over her back and chest as well. This case illustrates the potential for significant systemic dapsone absorption even with daily topical dosing and demonstrates the need for clear anticipatory guidance to prevent the potential morbidity and mortality associated with methemoglobinemia from improper topical dapsone use.

Hepatic deficiency of the pioneer transcription factor FoxA restricts hepatitis B virus biosynthesis by the developmental regulation of viral DNA methylation.

The FoxA family of pioneer transcription factors regulates hepatitis B virus (HBV) transcription, and hence viral replication. Hepatocyte-specific FoxA-deficiency in the HBV transgenic mouse model of chronic infection prevents the transcription of the viral DNA genome as a result of the failure of the developmentally controlled conversion of 5-methylcytosine residues to cytosine during postnatal hepatic maturation. These observations suggest that pioneer transcription factors such as FoxA, which mark genes for expression at subsequent developmental steps in the cellular differentiation program, mediate their effects by reversing the DNA methylation status of their target genes to permit their ensuing expression when the appropriate tissue-specific transcription factor combinations arise during development. Furthermore, as the FoxA-deficient HBV transgenic mice are viable, the specific developmental timing, abundance and isoform type of pioneer factor expression must permit all essential liver gene expression to occur at a level sufficient to support adequate liver function. This implies that pioneer transcription factors can recognize and mark their target genes in distinct developmental manners dependent upon, at least in part, the concentration and affinity of FoxA for its binding sites within enhancer and promoter regulatory sequence elements. This selective marking of cellular genes for expression by the FoxA pioneer factor compared to HBV may offer the opportunity for the specific silencing of HBV gene expression and hence the resolution of chronic HBV infections which are responsible for approximately one million deaths worldwide annually due to liver cirrhosis and hepatocellular carcinoma.

Administration of Dexrazoxane Improves Cardiac Indices in Children and Young Adults With Acute Myeloid Leukemia (AML) While Maintaining Survival Outcomes.

Anthracycline-induced cardiotoxicity remains a significant contributor to late morbidity/mortality in children and young adults with acute myeloid leukemia (AML). The cardioprotectant dexrazoxane can be used as prophylaxis to diminish risk for cardiomyopathy but whether it affects risk of relapse in pediatric AML is unclear. Our institution adopted the use of dexrazoxane before anthracyclines administration for all oncology patients in 2011. We compared patients with AML (ages, 0 to 21 y) who received or did not receive dexrazoxane during the years 2008 to 2013. In total, 44 patients with AML (ages, 4.5 mo to 21.7 y) were included. We identified no statistical difference in 2-year event rate (62% vs. 50%, P=0.41) or 2-year overall survival (69% vs. 69%, P=0.53) between patients receiving (n=28) or not receiving (n=16) dexrazoxane. Ejection fraction (P=0.0262) and shortening fraction (P=0.0381) trended significantly higher in patients that received dexrazoxane compared with those that did not receive dexrazoxane. Utilization of the cardioprotectant dexrazoxane before anthracycline chemotherapy in pediatric patients with AML demonstrated no significant difference in either event rate or overall survival relative to institutional controls and seems to improve cardiac function indices. Further studies in this patient population are needed to confirm these findings.

Hospitalized Adolescents' Perspectives on Sexual and Reproductive Health Discussions.

OBJECTIVES: Experts recommend that providers discuss adolescent patients' sexual and reproductive health (SRH) at any health care encounter, including hospitalizations. The purpose of this qualitative study was to gain insight into hospitalized adolescents' experiences and perspectives on SRH discussions (SHDs) to better inform patient-centered care. METHODS: Private semistructured interviews were conducted with hospitalized adolescents aged 13 to 17 years. Interviews were coded and analyzed using thematic analysis. Themes were developed through an iterative process with focus on the primary research aim. RESULTS: Twenty participants were interviewed with a median age of 15.4 years. Adolescents expressed a range of preferences related to SHDs with providers. Themes included (1) experiences discussing SRH with providers, (2) SHDs during hospitalization, (3) communication preferences, and (4) perceptions of why providers initiate SHDs. Viewpoints about SHDs during hospitalizations varied, including that they addressed unmet needs, as well as that they seemed irrelevant to some participants. Aspects that facilitate SHDs include brevity with relevant depth, nonjudgmental provider demeanor, and reassurance of privacy. Some participants believed providers could judge the depth of discussion needed on the basis of the adolescent's age or personality. CONCLUSIONS: This study highlights variation in adolescents' preferences around SHDs with health care providers. Providers should initiate SHDs with statements of purpose and confidentiality. Given the variation in adolescents' perspectives, tools to privately collect self-reported behaviors before an SHD may help providers frame the conversation to the adolescent's specific SRH needs and communication style preferences.

Level of Supervision for the Entrustable Professional Activities Common to General Pediatrics and the Subspecialties Decreases from Residency to Fellowship.

OBJECTIVES: To compare level of supervision (LOS) ratings of graduating pediatric residents with their assessments as fellows for the five Entrustable Professional Activities (EPAs) common to general pediatrics and the subspecialties and to determine if the difference between ratings from residency to fellowship is less for the QI and Practice Management EPAs, since the skills needed to perform these may be less context-dependent. METHODS: We compared ratings of graduating residents with their assessments as fellows using LOS data from two sequential EPA studies. RESULTS: There were 65 ratings from 41 residents at the first fellow assessment. At graduation, most residents needed little to no supervision for all EPAs with 94% (61/65) of ratings level four or five. In contrast, only 5/65 (8%) of the first fellow assessments were level four or five. The ratings difference for the QI and Practice Management EPAs was similar to the others. CONCLUSIONS: LOS ratings for the EPAs common to generalists and subspecialists reset as residents become fellows. There was no evidence that the QI and Practice Management EPAs are less context-dependent. This study provides additional validity evidence for using these LOS scales to assess trainees in pediatric residency and fellowship.

Implementing Entrustable Professional Activities in Pediatric Fellowships: Facilitating the Process.

BACKGROUND AND OBJECTIVES: Entrustable professional activities (EPAs) will be used for initial certification by the American Board of Pediatrics by 2028. Less than half of pediatric fellowships currently use EPAs for assessment, yet all will need to adopt them. Our objectives were to identify facilitators and barriers to the implementation of EPAs to assess pediatric fellows and to determine fellowship program directors' (FPD) perceptions of EPAs and Milestones. METHODS: We conducted a survey of FPDs from 15 pediatric subspecialties. EPA users were asked about their implementation of EPAs, barriers encountered, and perceptions of EPAs. Nonusers were queried about deterrents to using EPAs. Both groups were asked about potential facilitators of implementation and their perceptions of Milestones. RESULTS: The response rate was 65% (575/883). Of these, 344 (59.8%) were EPA users and 231 (40.2%) were nonusers. Both groups indicated work burden as a barrier to implementation. Nonusers reported more barriers than users (mean [SD]: 7 [3.8] vs 5.8 [3.4], P < .001). Both groups identified training materials and premade assessment forms as facilitators to implementation. Users felt that EPAs were easier to understand than Milestones (89%) and better reflected what it meant to be a practicing subspecialty physician (90%). In contrast, nonusers felt that Milestones were easy to understand (57%) and reflected what it meant to be a practicing subspecialist (58%). CONCLUSIONS: Implementing EPA-based assessment will require a substantial investment by FPDs, facilitated by guidance and easily accessible resources provided by multiple organizations. Perceived barriers to be addressed include FPD time constraints, a need for additional assessment tools, and outcomes data.

Using Electronic Health Record Modifications to Increase Use of Adolescent Sensitive Notes.

OBJECTIVES: Confidentiality is imperative when caring for adolescents, yet the 21st Century Cures Act ensures guardian access to some of their child's documentation. Pediatric Hospital Medicine (PHM) history and physical (H&P) notes are visible to guardians, whereas adolescent sensitive notes (ASN) are not. Our aim was to decrease sexual history and substance use (SHSU) documentation in H&P notes. METHODS: This quality improvement study included adolescents ages 13 to 17 from August 1, 2020 to May 31, 2021. Interventions included disappearing help text added to PHM H&P template prompting placement of positive SHSU in the ASN, editing of disappearing help text to encourage copy and paste of all SHSU into ASN, and communication to providers. The primary outcome measure was documentation of SHSU in H&P notes. The process measure was presence of ASNs. The balancing measures were documentation of unapproved social history domains in the ASN and encounters with no SHSU documentation. Statistical process control was used for analysis. RESULTS: Four hundred fifty patients were included in this analysis. There was decreased documentation of SHSU within H&P notes from means of 58.4% and 50.4% to 8.4% and 11.4%, respectively. There was increased utilization of ASN from 22.8% to 72.3%. Special cause variation occurred. Other unapproved domains in the ASN decreased. Encounters with no SHSU were unchanged. CONCLUSIONS: The quality improvement intervention of disappearing help text in PHM H&Ps was associated with decreased documentation of SHSU within H&P notes and increased utilization of ASN. This simple intervention helps maintain confidentiality. Further interventions may include utilization of disappearing help text in other specialties.

After "The Talk": Adolescents' Perspectives Reveal Need for Improvement in Hospital Sexual Health Care Delivery.

OBJECTIVES: To fill access gaps for adolescents, addressing sexual and reproductive health (SRH) is recommended in nontraditional settings. In previous improvement work, we increased documentation of sexual history to >80% of adolescents hospitalized on our pediatric hospital medicine (PHM) service. This study assessed adolescents' perception of SRH conversations with hospital providers and the extent to which they were helpful. METHODS: Postdischarge survey of patients 13 to 17 years discharged from the PHM service at an academic children's hospital between August 2019 and March 2020. Survey items included demographics; whether confidential discussion of sexual health topics such as contraception, sexually transmitted infection (STI), and sexual orientation occurred; perceptions of these discussions, and sexual history. RESULTS: Eighty-three patients enrolled and 44 (53%) completed the survey after discharge. A total of 68% of respondents were female and median age was 15 years (interquartile range 14-16). A total of 77% reported discussing SRH privately with a PHM provider. A total of 18% recalled discussing condoms, and 63% rated the discussion helpful. A total of 27% of females reported discussing birth control, and 40% rated it helpful. A total of 57% recalled discussing sexual orientation, and 40% rated it helpful. None reported discussions of STI testing with PHM. Of the 23% who were sexually active, none reported being given condoms. CONCLUSIONS: Analysis of adolescent patient experiences identified opportunities for continued improvement in the content and quality of SRH discussions, specifically regarding offering STI testing, condom distribution, and sexual orientation conversations. Our work highlights the importance of incorporating patient-reported data into improvement work to ensure providers are addressing targeted gaps in adolescent care.

Overweight Infants Hospitalized for Bronchiolitis Associated With Severe Disease.

OBJECTIVES: Overweight negatively affects pediatric respiratory function. In this study, we evaluate if overweight is associated with more severe bronchiolitis in hospitalized infants. METHODS: This retrospective cohort study analyzed infants aged 30 to 365 days hospitalized for bronchiolitis from September 2019 to April 2020. Exclusion criteria included known risk factors for severe bronchiolitis, asthma treatment, or bacterial pneumonia. Weight-for-length z-score was categorized per the World Health Organization's growth assessments as overweight (z-score >2), underweight (z-score <-2), and standard weight (between -2 and ≤2). Primary outcomes included respiratory support, ICU stay, and local bronchiolitis score. Secondary outcomes included supplemental interventions. RESULTS: After exclusion criteria, 385 of 644 infants were categorized as overweight (n = 24), standard (n = 335), or underweight (n = 26). There were differences in need for respiratory support (overweight, 100%; standard weight, 81.8%; underweight, 76.9%; P = .03), highest support of high-flow nasal cannula (overweight, 75%; standard weight, 48%; underweight, 42%; P = .03), admission to ICU (overweight, 54.2%; standard weight, 21.5%; underweight, 34.7%; P < .001), and median bronchiolitis score (overweight, 8 [interquartile range 5-10]; standard weight, 4 [3-7]; underweight, 4 [3-7]; P = .01). Findings remained significant after age adjustments. Additionally, overweight experienced higher frequency of certain treatments. CONCLUSIONS: This study suggests overweight is associated with more severe bronchiolitis in hospitalized infants supported by increased respiratory support level, bronchiolitis scores, and interventions. Higher need for ICU admission may be related to high-flow nasal cannula limitations on the acute care floor.

An Opportunity in Cancer Prevention: Human Papillomavirus Vaccine Delivery in the Hospital.

OBJECTIVE: Pediatric hospitalizations are a missed opportunity for delivery of the human papilloma virus (HPV) vaccination. In this study, the authors' aim was to increase HPV vaccination rates among adolescents cared for by the pediatric hospital medicine (PHM) service at our academic children's hospital. METHODS: This quality improvement (QI) study included adolescents ≥13 years who were discharged from PHM. Interventions included: modification of discharge order sets to include vaccination status and provider training seminars regarding the delivery of the HPV vaccine. Follow-up materials were distributed to providers by e-mail. The primary outcome measure was adolescent HPV vaccination rates. Secondary outcome measures were adolescent meningococcal vaccination rates and accuracy of immunization status documentation. The balancing measure was length of stay (LOS). Data were collected via chart review. Statistical process control charts were used to analyze for special cause variation. RESULTS: From May 2019 through February 2020, 440 patients were included in this analysis. Throughout the study, HPV and meningococcal vaccination rates increased from a baseline median of 4.6% to 21.2% and 8.3% to 26.6%, respectively. HPV vaccination was not significantly associated with sex, HPV dose due, or admitting service. Accuracy of immunization status documentation and LOS remained unchanged. CONCLUSIONS: Using QI methodology we were successful in increasing HPV and meningococcal vaccination rates among hospitalized adolescents. Considering the relationship of these 2 vaccines is a potential topic of future work. Discerning the correct immunization status at time of admission may be a potential opportunity for improvement in future work.

Quality Initiative to Increase Delivery of Adolescent Hospital-Based Reproductive Health Care.

OBJECTIVES: Hospitals are an important nontraditional setting in which to address adolescent reproductive health. However, opportunities for intervention are frequently missed, especially for boys and patients hospitalized for noningestion complaints. Our global aim was to increase delivery of reproductive health care to adolescents hospitalized through our children's hospital Pediatric Hospital Medicine service. METHODS: We performed 2 quality improvement intervention cycles: (1) provider education and monthly reminder e-mails and (2) an automated electronic health record (EHR) adolescent history and physical note template with social history prompts while discontinuing reminder e-mails. The primary outcome measure was sexual history documentation (SHD). Secondary measures were sexually transmitted infection (STI) testing and contraception provision. Statistical process control charts were used to analyze effectiveness of interventions. RESULTS: From July 2018 through June 2019, 528 Primary Hospital Medicine encounters were included in this study and compared with published baseline data on 150 encounters. Control charts revealed a special cause increase in SHD from 60% to 82% overall, along with 37% to 73% for boys and 57% to 80% for noningestion hospitalizations. Increased SHD correlated with cycle 1 and was maintained through cycle 2. Percent STI testing significantly increased but did not shift or trend toward special cause variation. Contraception provision, length of stay, and patient relations consultations were not affected. CONCLUSIONS: The interventions were successful in increasing SHD, including among boys and noningestion hospitalizations. The EHR enhancement maintained these increases after reminder emails were discontinued. Future interventions should specifically address STI testing and provision of contraception.

Characteristics and Outcomes of Sepsis Presenting in Inpatient Pediatric Settings.

OBJECTIVE: The pediatric sepsis literature lacks studies examining the inpatient setting, yet sepsis remains a leading cause of death in children's hospitals. More information is needed about sepsis arising in patients already hospitalized to improve morbidity and mortality outcomes. This study describes the clinical characteristics, process measures, and outcomes of inpatient sepsis cases compared with emergency department (ED) sepsis cases within the Improving Pediatric Sepsis Outcomes data registry from 46 hospitals that care for children. METHODS: This retrospective cohort study included Improving Pediatric Sepsis Outcomes sepsis cases from January 2017 to December 2019 with onset in inpatient or ED. We used descriptive statistics to compare inpatient and ED sepsis metrics and describe inpatient sepsis outcomes. RESULTS: The cohort included 26 855 cases; 8.4% were inpatient and 91.6% were ED. Inpatient cases had higher sepsis-attributable mortality (2.0% vs 1.4%, P = .025), longer length of stay after sepsis recognition (9 vs 5 days, P <.001), more intensive care admissions (57.6% vs 54.1%, P = .002), and greater average vasopressor use (18.0% vs 13.6%, P <.001) compared with ED. In the inpatient cohort, >40% of cases had a time from arrival to recognition within 12 hours. In 21% of cases, this time was >96 hours. Improved adherence to sepsis treatment bundles over time was associated with improved 30-day sepsis-attributable mortality for inpatients with sepsis. CONCLUSIONS: Inpatient sepsis cases had longer lengths of stay, more need for intensive care, and higher vasopressor use. Sepsis-attributable mortality was significantly higher in inpatient cases compared with ED cases and improved with improved sepsis bundle adherence.

Intent, Substance, and Care: Characteristics of Adolescent Ingestion Hospitalizations.

OBJECTIVES: To characterize the patient population of adolescents hospitalized at a tertiary center for ingestions and identify opportunities to improve health care delivered and resources offered to these adolescents. METHODS: Retrospective study of a consecutive sample of adolescent patients (12-18 years old) discharged from the hospitalist service at a large academic pediatric tertiary care center from May 2017 through April 2018. Data were collected regarding patient and hospital encounter characteristics including length of stay, admission service, reason for ingestion, substance(s) ingested, previous suicidal ideation (SI) screening, sexual history documentation, pregnancy testing, disposition at discharge and follow-up with primary care physicians (PCPs). RESULTS: Most hospitalizations for ingestions were reported as intentional suicide attempts (79%). Most commonly, adolescents ingested exclusively prescription medications (45%) or over-the-counter medications (32%). Of adolescents with a reported suicide attempt for whom PCP records were available, 56% did not have SI screening documented in the medical record. One-quarter of adolescents hospitalized for an ingestion did not have a sexual history documented, and 11% of female patients were not tested for pregnancy before discharge. A majority (66%) of the adolescents with PCP records available did not follow-up with their PCP within 2 months after their hospitalization. CONCLUSIONS: On the basis of our study results, opportunities to improve adolescent health include increased screening for SI and mental health symptoms throughout medical environments, comprehensive risk assessment of all adolescents hospitalized for an ingestion and increased guidance for caregivers of adolescents regarding prescription and over-the-counter medication storage in the home.

Did You Get My Snap? Snapchat as a Health Education Tool for Hospitalized Adolescents.

PURPOSE: Given the popularity of Snapchat with teens, we used this tool to disseminate reproductive health information to adolescent patients. METHODS: We developed a unique Snapcode linked to educational materials located on a cloud service and accessible via the Snapchat app. The Snapcode was printed on a business card and distributed to hospitalized adolescents. We tracked card distribution and how often the materials were accessed through our cloud service and through Snapchat. RESULTS: A total of 236 cards were distributed to teens with 117 unique scans and 122 views of the PDF. Of the teens who received the card (N = 236), 49.5% of teens used the Snapcode to access reproductive health education. CONCLUSIONS: Snapchat is a promising way to distribute educational materials to adolescents in a discrete manner on a platform many teens use. This mechanism demonstrates a way for providers to use Snapchat as a tool to provide education to hospitalized adolescents.

Letting Residents Lead: Implementing Resident Admission Triage Call Curriculum and Practice.

BACKGROUND AND OBJECTIVES: Graduating residents are expected to be competent in triaging patients to appropriate resources. Before 2017, pediatric residents were not involved in admission triage decisions. In 2017, after implementing an admission triage curriculum (ATC), residents had opportunities to be involved in overnight admission calls with the emergency department (ED), which were initially supervised (joint calls), and as skills progressed, residents conducted calls and admitted patients independently. We implemented and evaluated the impact of a graduated ATC intervention bundle on pediatric resident opportunities to participate in admission triage, while monitoring resident confidence, the ED experience, and patient safety. METHODS: We evaluated the impact of our ATC using quality improvement methodology. The primary outcome was the frequency of resident participation in joint and independent triage calls. Other measures included resident confidence, the ED clinician experience, and patient safety. Resident confidence and the ED clinician experience were rated via surveys. Safety was monitored with daytime hospitalist morning assessments and postadmission complications documented in the medical record. RESULTS: The percent of joint calls with the hospitalist increased from 7% to 88%, and 125 patients were admitted independently. Residents reported significant increases in adequacy of triage training and confidence in 3 triage skills (P < .001) after ATC. There were no complications or safety concerns on patients admitted by residents. ED clinicians reported increased admitting process efficiency and satisfaction. CONCLUSIONS: Our ATC intervention bundle increased the number of admission decision opportunities for pediatric residents, while increasing resident triage confidence, maintaining safety, and improving ED clinician experience.

Addressing Reproductive Health in Hospitalized Adolescents-A Missed Opportunity.

PURPOSE: Adolescents are at high risk for sexually transmitted infections (STIs) and pregnancy. Since many adolescents have poor access to preventive care, hospitalizations present a critical opportunity to address adolescents' reproductive health. The purpose of this study was to assess provision of reproductive health services within a hospital setting. METHODS: Retrospective study of a consecutive sample of adolescent patients aged 13 years and older hospitalized on the hospitalist service at a large academic pediatric tertiary care center. Measures included sexual history documentation, pregnancy and STI testing, Human papillomavirus immunization status and administration, and provision of contraception. RESULTS: Only 55% of 150 patients had sexual history documentation, and of those, 47% endorsed sexual activity. Associations with increased likelihood of sexual history documentation included female patients (67% vs. 36%, p < .01), hospitalizations for ingestion (71% vs. 48%, p < .01), hospitalizations to hospital medicine compared with critical care (59% vs. 14%, p < .01), and admission note written by an intern compared with a senior resident, advanced practice provider, or fellow (67% vs. 44%, 29%, 13%, p < .01). Eighteen patients (12%) were tested for STIs. Only 19% of patients due for human papillomavirus immunization received it. Sixty percent of females received a pregnancy test. Contraception was provided in two encounters (2% of females). CONCLUSIONS: Results demonstrate a substantial missed opportunity to provide reproductive health services to hospitalized adolescents. Providers in hospital settings should optimize the opportunity to screen for sexual activity and reproductive health needs, provide indicated services, and offer education regarding reproductive health to hospitalized adolescents.