Outcomes of a dexamethasone-prednisone combination treatment course for status asthmaticus.

OBJECTIVES: Dexamethasone has become the standard of care for pediatric patients with status asthmaticus in the emergency department (ED) setting. Inpatient providers often must decide between continuing the second dose of dexamethasone or transitioning to prednisone. The effectiveness of receiving dexamethasone followed by prednisone (combination therapy) compared to only prednisone or dexamethasone remains unclear. This study compares patient characteristics and ED reutilization/hospital readmission outcomes of dexamethasone, prednisone, and combination therapy for inpatient asthma management. METHODS: A retrospective study was conducted at our tertiary children's hospital of children aged 2 to 18 years hospitalized between March 2016 and December 2018 with a primary discharge diagnosis of asthma, reactive airway disease, or bronchospasm. The differences between steroid groups were compared using Fisher's exact or Chi-square tests for categorical variables, and a Kruskal-Wallis test for continuous variables. A multivariable logistic regression was performed to analyze ED reutilization and hospital readmission rates. RESULTS: 1697 subjects met inclusion criteria. 115 (6.8%) patients received dexamethasone, 597 (35.2%) received prednisone, and 985 (58.0%) received combination therapy. Patients prescribed combination therapy had a lower exacerbation severity than patients prescribed prednisone, but higher severity than patients prescribed dexamethasone (p < .001, p = .001, respectively). Dexamethasone and combination therapy were not associated with increased 30-day ED reutilization/hospital readmissions compared to prednisone (p > .05). CONCLUSIONS: In our study, most patients hospitalized for status asthmaticus received combination therapy. Despite the differences in severity between steroid groups, outcomes of combination therapy and dexamethasone monotherapy, as measured by frequency of ED reutilizations/hospital readmissions, are comparable to prednisone monotherapy.

Accelerated Episodic Luteinizing Hormone Release Accompanies Blunted Progesterone Regulation in PCOS-like Female Rhesus Monkeys (Macaca Mulatta) Exposed to Testosterone during Early-to-Mid Gestation.

BACKGROUND/AIMS: Ovarian theca cell hyperandrogenism in women with polycystic ovary syndrome (PCOS) is compounded by androgen receptor-mediated impairment of estradiol and progesterone negative feedback regulation of episodic luteinizing hormone (LH) release. The resultant LH hypersecretion, likely the product of accelerated episodic release of gonadotropin-releasing hormone (GnRH) from the median eminence of the hypothalamus, hyperstimulates ovarian theca cell steroidogenesis, enabling testosterone (T) and androstenedione excess. Prenatally androgenized (PA) female monkeys exposed to fetal male levels of T during early-to-mid gestation, when adult, demonstrate PCOS-like traits, including high T and LH levels. This study tests the hypothesis that progesterone resistance-associated acceleration in episodic LH release contributes to PA monkey LH excess. METHODS: A total of 4 PA and 3 regularly cycling, healthy control adult female rhesus monkeys of comparable age and body mass index underwent (1) a 10 h, frequent intravenous sampling assessment for LH episodic release, immediately followed by (2) IV infusion of exogenous GnRH to quantify continuing pituitary LH responsiveness, and subsequently (3) an SC injection of a progesterone receptor antagonist, mifepristone, to examine LH responses to blockade of progesterone-mediated action. RESULTS: Compared to controls, the relatively hyperandrogenic PA females exhibited ~100% increase (p = 0.037) in LH pulse frequency, positive correlation of LH pulse amplitude (p = 0.017) with androstenedione, ~100% greater increase (p = 0.034) in acute (0-10 min) LH responses to exogenous GnRH, and an absence (p = 0.008) of modest LH elevation following acute progesterone receptor blockade suggestive of diminished progesterone negative feedback. CONCLUSION: Such dysregulation of LH release in PCOS-like monkeys implicates impaired feedback control of episodic release of hypothalamic GnRH reminiscent of PCOS neuroendocrinopathy.

Impact of COVID-19 on Acute Care Hospitalizations for Suicidality.

BACKGROUND AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic contributed to the public health crisis for pediatric mental health. We characterized our local patient population presenting with suicidality or suicide attempts before and after the pandemic by examining: 1. frequencies of hospitalizations for suicidality to determine whether they differed by age, legal sex, race and ethnicity, or socioeconomic status; 2. average length of stay and discharge disposition; 3. 7-, 30-, and 365-day reutilization rates; and 4. admission trends during COVID-19 surges. METHODS: Retrospective data between March 2018 and March 2022 was analyzed, including patients ages 10 to 17 years hospitalized for either suicidality or a suicide attempt at 1 freestanding tertiary care pediatric medical hospital in the Midwest. Encounters were divided into 2 categories on the basis of the COVID-19 pandemic: "Prelockdown" (March 1, 2018-March 12, 2020) and "postlockdown" (March 13, 2020-March 31, 2022). Patients were limited to 1 presentation pre- and postlockdown. We analyzed frequencies using means and SDs, categorical data using χ2 and Fisher's exact tests, and continuous data with t tests. RESULTS: A total of 1017 encounters were included, stratified into pre- and postlockdown groups for analysis (909 encounters, 889 unique patients). There was a significant difference in 365-day reutilization pre- and postlockdown when analyzing re-presentation to the emergency department (P = .025) and hospital readmission (P = .006). Admissions incrementally increased after the COVID-19 alpha variants in September 2020 and again after the delta variant in August 2021. CONCLUSIONS: The COVID-19 pandemic further intensified the already critical issue of pediatric mental health, demonstrating increased reutilization in the year after their initial presentation and an increase in admissions after the alpha variant.

An Interprofessional Initiative to Address Tests Pending at Discharge for Hospitalized Pediatric Patients.

INTRODUCTION: Pediatric hospitalized patients often are discharged before all lab tests are completed. Given the risk of medical errors related to inadequate test follow-up, we piloted a collaborative initiative to address tests pending at discharge (TPAD) within our pediatric hospital medicine section. Our objectives were to delineate the responsibilities of case managers and pediatric hospital medicine clinicians in addressing these tests and to establish a communication process. METHODS: We formed an interprofessional team and performed a current state assessment, including a survey to pediatric hospital medicine clinicians to assess time spent following up TPAD and confidence that results were followed up in a timely and appropriate manner. We obtained a list of 1450 individual TPAD for the previous 9 months using an electronic health record data query, from which a list of 26 common and straightforward labs were identified for case manager follow-up. A shared case manager Epic Inbasket for TPAD was created and was checked twice daily. We developed a phased approach to establish a workflow for follow-up. DISCUSSION: The case manager partnership was launched in 4 phases for the duration of the 6-month pilot. However, due to duplication of work and less value of case managers addressing straightforward labs, the pilot was stopped. A more effective and mutually beneficial role for pediatric hospital medicine attendings and case managers may be to have the case managers address complex TPAD and communicate with primary care clinicians and families.

Current Practice and Rationale of Prescribing Dexamethasone for Pediatric Patients Hospitalized for Asthma.

OBJECTIVE: Dexamethasone use for pediatric asthma exacerbations in the emergency department is supported in literature as a beneficial alternative to prednisone; however, there is limited data in the hospital setting. This study assesses factors that influence pediatric hospital providers' steroid choice for patients hospitalized for status asthmaticus. METHODS: A survey was developed to assess factors influencing steroid prescribing practices. It was completed by our institution's pediatric hospitalists and advance practice providers in June 2019 and April 2021. Responses were summarized using descriptive statistics, interrater agreement was analyzed with Cohen's kappa statistic, and bivariate comparisons were analyzed with chi-square tests. RESULTS: Thirty-six of 39 providers completed the survey in 2019; 31 of 43 completed it in 2021. They reported wide disagreement with the use of dexamethasone in both surveys (2019 vs 2021: 34% vs 55% in favor, 43% vs 35% neutral, 23% vs 9% opposing, P = 0.191). There was a self-reported increase in prescribing frequency of dexamethasone from 2019 to 2021 (P = 0.007). There was moderate agreement with prescribing dexamethasone for patients with poor oral tolerance or medication noncompliance (2019: κ = 0.485, P = 0.002; 2021: κ = 0.281, P = 0.048). There was moderate agreement with prescribing prednisone for patients with higher severity of baseline asthma or current exacerbation (2019: κ = 0.537, P < 0.001; 2021: κ = 0.500, P < 0.001). Length of the dexamethasone course did not influence prescribing practices (P > 0.05). CONCLUSIONS: In our inpatient setting, prednisone is preferred for severe asthma cases, while dexamethasone is preferred for patients with poor oral tolerance or medication noncompliance. The length of the dexamethasone course did not influence providers' steroid choice.

Improving Documentation of Postdischarge Issue Mitigation during Postdischarge Phone Calls.

Postdischarge phone calls (PDPCs) are recommended to identify and mitigate postdischarge issues such as missed follow-up appointments, medication errors, and failure to activate contingency plans. A current state assessment showed variability in documenting PDPC content and postdischarge issue mitigation. Therefore, the primary aim was to improve the postdischarge issue mitigation documentation rate from 65% to 100% over 16 months. Methods: An interdisciplinary quality improvement team used the Model for Improvement to perform planned sequential interventions over 16 months. The outcome measure was documentation of postdischarge issue mitigation. Process measures included PDPC template use and completion and postdischarge issue identification. Balancing measures included call attempts and caller perceptions of ease of documentation. Interventions included creating a flowsheet note template, creating caller template training sessions, and sharing team data and feedback. We gathered data via reports generated from the electronic medical record, chart review, and survey. Data were analyzed using statistical process control charts and established rules for detecting special cause variation. Results: The postdischarge issue mitigation documentation increased from 65% to 91% over 16 months. Template use and completion increased from 0% to 100% and 98%, respectively. The number of postdischarge issues identified remained unchanged. Call attempts increased from 40% to 59%. Caller perceptions remained unchanged. Conclusions: Documentation of postdischarge issues and issue mitigation promotes adequate communication with the patient's care providers, improving the quality and safety of care. Data sharing to promote team engagement was the key factor in improving documentation of postdischarge issue mitigation.

Developing Validity Evidence for a Patient- and Family-Centered Rounds Presenter Empowerment Action Rating Tool.

BACKGROUND: Training in patient- and family-centered care is endorsed by the American Academy of Pediatrics (AAP) and the Accreditation Council for Graduate Medical Education (ACGME) for learners. The AAP recommends patient- and family-centered rounds (PFCR) during inpatient care. The PEA-21 (21-item Presenter Empowerment Action checklist) was developed to evaluate presenter behavior during PFCR. OBJECTIVE: To gather validity evidence for the PEA-21 in evaluating third year medical student and intern presentations during PFCR in the domains of Data Accuracy, Communication Skills, Assessment and Plan Formation, and Family Interaction. METHODS: A 24-month prospective cohort study of students and interns presenting on PFCR. Content, response process, internal structure, and relationship with other variables were assessed. RESULTS: Data were collected from 101 rounds (758 individual patient encounters), both on pediatric subspecialty and hospital medicine teams. Presenters included third- and fourth-year medical students and interns in pediatrics, internal medicine-pediatrics, and family-medicine. Intraclass correlations between observers ranged from 0.5 to 0.72. Internal consistency showed α >0.7 for 3 of 4 domains. Interns scored higher than students across domains (P< .01), but students' scores improved throughout their rotations (d = 0.2-0.8). Both groups performed lowest in the Family Interaction Domain. CONCLUSIONS: The PEA-21 showed strong validity properties including content, response process, internal structure, and relationship with other variables and can be used by educators to assess learners' skill levels and provide formative feedback to both medical students and interns. Targeted efforts are needed to improve skills within the Family Interaction Domain for both medical students and interns.

Parental Perception of Care for Infants With Fever During Hospitalization.

OBJECTIVE: To assess parental perceptions regarding reason for and length of their infant's hospitalization and to understand family preferences for time of discharge. METHODS: Participants included parents of infants who were noncomplex, well-appearing infants, aged 7 to 60 days, and evaluated for fever without a source. A 5-question structured interview was administered over a 6-month period. RESULTS: Parents understood that fever necessitated admission for further diagnostic evaluation and that admissions would be no more than 48 hours if bacterial cultures were negative. Over one-third of patients' families preferred overnight discharge. DISCUSSION: Parents recognize reasons for admission and the rationale for length of stay. Preferences for time of discharge can serve as a starting point for shared decision-making between parents and providers.

Parents Support Teach-back, Demonstration, and a Postdischarge Phone Call to Augment Discharge Education.

OBJECTIVES: To identify caregiver preferences for discharge education components, content, and techniques. METHODS: Before discharge education, a 9-question structured interview was performed with caregivers of children from 2 populations admitted to the hospital medicine service: patients with asthma (age 2-17 years) or children who were not dependent on technology (age <2 years). McNemar's tests were used to evaluate for significant differences between response options. Open coding was used for theme development to interpret qualitative responses about information caregivers wished to receive before leaving the hospital. RESULTS: The interview was administered to 100 caregivers. More than 90% of caregivers believed that instruction regarding follow-up appointments, medications, and reasons to call the pediatrician or return to the emergency department were important aspects of discharge education. Caregivers also identified a desire for education on their child's condition, care at home, and illness prevention. Most caregivers reported that teach-back, early discharge education, and a postdischarge phone call would be beneficial. Caregivers varied in their preferences for written, verbal, and video instruction, whereas live demonstration was rated almost universally as an effective method by 97% of caregivers (P < .0001). CONCLUSIONS: In our study, we provide insight into caregivers' perspectives on the content, timing, and style of education needed to promote a safe transition of care from the hospital to the home. These findings add caregiver support to the expert consensus in Project Improving Pediatric Patient-Centered Care Transitions and elucidate additional themes to aid in further study and optimization of discharge education.

Teaching Inpatient Bedside Presenter Empowerment Actions During an Interactive Workshop.

Introduction: Medical students and interns are the principal communicators during inpatient bedside patient- and family-centered rounds. Excellent presenters are able to share information during rounds in a manner that is accurate, effective, and easy for all to understand. We previously identified the behaviors of excellent presenters and developed a term for them: presenter empowerment actions. Methods: To promote the use of presenter empowerment actions, an interactive workshop was created to teach them to medical students and interns. This educational summary contains information on how to facilitate a workshop to promote presenter empowerment actions, which includes both a didactic presentation and an interactive game. Results: Interns reported increases in confidence and knowledge of empowerment actions, as well as strong intent to incorporate presenter empowerment actions during inpatient rounds. Discussion: A workshop with an interactive game is an effective way to teach empowerment actions to learners. To reinforce presenter empowerment action use after the workshop, we recommend direct observation using the Suspected Observable Presenter Empowerment Action Checklist to provide formative feedback to the presenters.