Barriers and Facilitators to Chronic Red Cell Transfusion Therapy in Pediatric Sickle Cell Anemia.

Background: Chronic red cell transfusion (CRCT) therapy is one of a few effective disease-modifying therapies for children with sickle cell anemia (SCA). CRCT is recommended for primary and secondary stroke prevention for at-risk children with SCA and is sometimes used for other disease-related complications. However, CRCT can be resource- and time-intensive for patients/families, providers, and organizations. This study was conducted to provide a comprehensive, multilevel examination of barriers and facilitators to transfusion therapy in children with SCA from health care provider and caregiver perspectives. Methods: A qualitative descriptive approach was used to conduct key informant interviews in a sample of 26 caregivers and 25 providers across the United States. Interviews were analyzed using directed content analysis with the Multilevel Ecological Model of Health as an initial coding framework and the constant comparison method. Results: Ten barrier themes and 10 facilitator themes emerged across all ecological levels. Themes most commonly occurred on the patient and organizational levels. Key barriers themes included Logistical Challenges, Obtaining and Maintaining Venous Access, Alloantibodies/Alloimmunization and Reactions, and Iron Overload and Adherence to Chelation Therapy. Key facilitator themes included Nursing and Non-nursing Staff Support, Positive Child/Family Experiences, Logistical Help and Social Resources, Blood Bank and Access to Blood, and Transfusion-Specific Resources. Discussion: The comprehensive understanding of multilevel barriers and facilitators to transfusion therapy, including the role of nursing, in children with SCA can inform strategies to improve CRCT for patients/families and providers and can also be applied by organizations seeking to implement transfusion services for SCA.

Hospital-based ovarian cancer patient traceback program results in minimal genetic testing uptake.

OBJECTIVE: To determine the feasibility of hospital-based genetic counseling and testing (GC/T) Traceback for Ovarian Cancer (OC) patients, as proposed by the Division of Cancer Prevention and the Division of Cancer Control and Population Sciences, National Cancer Institute. METHODS: Living patients with OC were sent a letter explaining the availability of guideline-supported GC/T for at least BRCA1/2 and surrogates of deceased patients were called on the telephone. Outcomes of contact attempts were systematically recorded and statistically described. RESULTS: 598 Traceback-eligible OC patients diagnosed from 2006 to 2016 were identified (163 presumed-living and 435 deceased). Two living patients called our office and scheduled an appointment for GC/T after receiving a letter. For surrogates of prior patients, successful contact occurred in 25% of call attempts. Fourteen individuals (2 living patients and 12 surrogates) underwent genetic counseling. Of those 14, 10 individuals consented to genetic testing and 5 followed through with sample collection. None of these individuals had pathogenic variants (PVs). When surrogate call notes were reviewed, 58% reflected positive responses to contact, however 42% were noted to have negative or indifferent responses, which were most common among spouses. Total time spent for hospital-based Traceback was 109 h. CONCLUSIONS: Overall, hospital-based Traceback via letter and telephone contact of surrogates is time-intensive and results in minimal uptake of GC/T. To practically execute this type of outreach program, health systems should consider collection of alternative contact information to allow for electronic communication of patient surrogates. Our study also underscores the importance of timely GC/T while patients are in active cancer care.

Preventing Home Medication Administration Errors.

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Transcranial Doppler Screening in a Current Cohort of Children With Sickle Cell Anemia: Results From the DISPLACE Study.

Stroke prevention guidelines for sickle cell anemia (SCA) recommend transcranial Doppler (TCD) screening to identify children at stroke risk; however, TCD screening implementation remains poor. This report describes results from Part 1 of the 28-site DISPLACE (Dissemination and Implementation of Stroke Prevention Looking at the Care Environment) study, a baseline assessment of TCD implementation rates. This report describes TCD implementation by consortium site characteristics; characteristics of TCDs completed; and TCD results based on age. The cohort included 5247 children with SCA, of whom 5116 were eligible for TCD implementation assessment for at least 1 study year. The majority of children were African American or Black, non-Hispanic and received Medicaid. Mean age at first recorded TCD was 5.9 and 10.5 years at study end. Observed TCD screening rates were unsatisfactory across geographic regions (mean 49.9%; range: 30.9% to 74.7%) independent of size, institution type, or previous stroke prevention trial participation. The abnormal TCD rate was 2.9%, with a median age of 6.3 years for first abnormal TCD result. Findings highlight real-world TCD screening practices and results from the largest SCA cohort to date. Data informed the part 3 implementation study for improving stroke screening and findings may inform clinical practice improvements.

Changes in Care Delivery for Children With Sickle Cell Anemia During the COVID-19 Pandemic.

BACKGROUND: Specialty care for children with sickle cell disease (SCD) may be disrupted during the coronavirus (COVID-19) pandemic. Our DISPLACE consortium includes 28 pediatric SCD centers. METHODS: In May 2020, we surveyed the consortium on the impact of COVID-19 on their practice focusing on transcranial Doppler ultrasound, chronic red cell transfusions, telehealth, and COVID-19 testing. OBSERVATION: Twenty-four DISPLACE providers completed the survey. Transcranial Doppler ultrasound screening decreased to 67% but chronic red cell transfusions remained at 96%. Most investigators (92%) used telehealth and 40% of providers had patients test positive for COVID-19. CONCLUSION: The COVID-19 pandemic has affected routine care and necessitated changes in practice in SCD.

Practice patterns for neuroimaging and transfusion therapy for management of neurologic complications in sickle cell anemia: DISPLACE consortium.

BACKGROUND: Children with sickle cell anemia (SCA) are at risk for neurologic complications (stroke and silent cerebral infarct). The 2014 National Heart, Lung, and Blood Institute (NHLBI) guidelines for sickle cell disease include recommendations for initiation and maintenance of chronic red cell transfusion (CRCT) therapy for children with SCA at risk for or with ischemic stroke. The guidelines do not include well-delineated recommendations for cerebral imaging for stroke screening. The purpose of this study was to evaluate current stroke risk screening, prevention, and intervention practices amongst the Dissemination and Implementation of Stroke Prevention Looking at the Care Environment (DISPLACE) study sites. PROCEDURE: A survey was administered to DISPLACE site principal investigators to identify current stroke prevention practices relative to the Stroke Prevention Trial in Sickle Cell Anemia (STOP) study protocols and the 2014 NHLBI guidelines. Data were analyzed using descriptive statistics and line-by-line analysis of comments. RESULTS: Sites consistently applied NHLBI recommendations to initiate CRCT for ischemic stroke and abnormal transcranial Doppler ultrasound (TCD) results. Similarly, nearly all sites reported obtaining an magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) following an abnormal TCD result. There was wide variation for other indications for MRI/MRA, frequency of MRI/MRA, and other neurological indications for initiating CRCT. CONCLUSIONS: Guideline-based practices for preventing ischemic stroke through TCD and CRCT initiation were evident in nearly all sites. Wide variation in practices pertaining to MRI/MRA exists, potentially influenced by more recent stroke prevention trials. New guidelines from the American Society of Hematology were published in April 2020, which may reduce practice variation.

Practice patterns for stroke prevention using transcranial Doppler in sickle cell anemia: DISPLACE Consortium.

BACKGROUND: Children with sickle cell anemia (SCA) are at increased risk for stroke. In 2014, the National Heart, Lung, and Blood Institute (NHLBI) developed guidelines for stroke prevention in SCA informed by the Stroke Prevention Trial in Sickle Cell Anemia (STOP) and Optimizing Primary Stroke Prevention in Sickle Cell Anemia (STOP II) trials. The guidelines specify the use of transcranial Doppler (TCD) screening and intervention with chronic red cell transfusions (CRCT) in children with SCA who have TCD indication of high stroke risk. The purpose of this study was to describe real-world practice patterns of stroke risk screening and intervention in sites that participated in the Dissemination and Implementation of Stroke Prevention Looking at the Care Environment (DISPLACE) Consortium. PROCEDURE: Site investigators completed a survey during the formative stages of the study to evaluate their TCD practices relative to the STOP studies. Descriptive statistics and analysis of free-text comments for more complex practices were evaluated. RESULTS: Results suggested universal acceptance of annual TCD screening and initiation of CRCT following an abnormal result among the DISPLACE Consortium, consistent with NHLBI recommendations. However, there was wide variation in methods for conducting TCD screenings (eg, dedicated Doppler vs TCD imaging), classifying TCD results, and actions taken for conditional and inadequate results. CONCLUSIONS: Annual TCD screening and initiation of CRCT are critical stroke prevention practices that were universally embraced in the consortium. Additional research would be beneficial for informing clinical practices for areas in which guidelines are absent or unclear.

Adolescent Risk Screening Instruments for Primary Care: An Integrative Review Utilizing the Donabedian Framework.

Adolescent risk-taking behavior choices can affect future health outcomes. The purpose of this integrative literature review is to evaluate adolescent risk screening instruments available to primary care providers in the United States using the Donabedian Framework of structure, process, and outcome. To examine the literature concerning multidimensional adolescent risk screening instruments available in the United States for use in the primary care setting, library searches, ancestry searches, and Internet searches were conducted. Library searches included a systematic search of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Premier, Health Source Nursing Academic Ed, Medline, PsycINFO, the Psychology and Behavioral Sciences Collection, and PubMed databases with CINAHL headings using the following Boolean search terms: "primary care" and screening and pediatric. Criteria for inclusion consisted of studies conducted in the United States that involved broad multidimensional adolescent risk screening instruments for use in the pediatric primary care setting. Instruments that focused solely on one unhealthy behavior were excluded, as were developmental screens and screens not validated or designed for all ages of adolescents. In all 25 manuscripts reviewed, 16 screens met the inclusion criteria and were included in the study. These 16 screens were examined for factors associated with the Donabedian structure-process-outcome model. This review revealed that many screens contain structural issues related to cost and length that inhibit provider implementation in the primary care setting. Process limitations regarding the report method and administration format were also identified. The Pediatric Symptom Checklist was identified as a free, short tool that is valid and reliable.

Contemporary bloodletting in cardiac surgical care.

BACKGROUND: Health care providers are seldom aware of the frequency and volume of phlebotomy for laboratory testing, bloodletting that often leads to hospital-acquired anemia. Our objectives were to examine the frequency of laboratory testing in patients undergoing cardiac surgery, calculate cumulative phlebotomy volume from time of initial surgical consultation to hospital discharge, and propose strategies to reduce phlebotomy volume. METHODS: From January 1, 2012 to June 30, 2012, 1,894 patients underwent cardiac surgery at Cleveland Clinic; 1,867 had 1 hospitalization and 27 had 2. Each laboratory test was associated with a test name and blood volume. Phlebotomy volume was estimated separately for the intensive care unit (ICU), hospital floors, and cumulatively. RESULTS: A total of 221,498 laboratory tests were performed, averaging 115 tests per patient. The most frequently performed tests were 88,068 blood gas analyses, 39,535 coagulation tests, 30,421 complete blood counts, and 29,374 metabolic panels. Phlebotomy volume differed between ICU and hospital floors, with median volumes of 332 mL and 118 mL, respectively. Cumulative median volume for the entire hospital stay was 454 mL. More complex procedures were associated with higher overall phlebotomy volume than isolated procedures; eg, combined coronary artery bypass grafting (CABG) and valve procedure median volume was 653 mL (25th/75th percentiles, 428 of 1,065 mL) versus 448 mL (284 of 658 mL) for isolated CABG and 338 mL (237 of 619) for isolated valve procedures. CONCLUSIONS: We were astonished by the extent of bloodletting, with total phlebotomy volumes approaching amounts equivalent to 1 to 2 red blood cell units. Implementation of process improvement initiatives can potentially reduce phlebotomy volumes and resource utilization.

Is it time to refine? An exploration and simulation of optimal antibiotic timing in general surgery.

BACKGROUND: Postoperative infections increase morbidity, resource use, and costs. Our objective was to examine whether within guideline recommendations an optimal time exists for an initial dose of antibiotic to reduce postoperative infections in general surgery, and to simulate the magnitude of a reduction in infections should an optimal time be implemented. STUDY DESIGN: The population consisted of 6,731 patients who underwent 7,095 general surgery procedures between January 5, 2006 and June 25, 2012. Patients with pre-existing infections, such as pneumonia and sepsis, and patients with no recorded use of antibiotics were excluded, as were patients on vancomycin and surgical procedures longer than 4 hours in duration. The final analysis dataset included 4,453 patients. The National Surgical Quality Improvement Program was used for perioperative variables and outcomes. The end point was a composite of wound disruption; superficial, deep, organ space, surgical site infections; and sepsis. Semi-parametric logistic regression was used to study the association between antibiotic timing and infection. RESULTS: There were 444 (10%) patients with a primary end point of infectious complication. A nonlinear "bowl-shaped" relationship between duration of interval from antibiotic administration and surgical incision and infection was observed; lowest risk corresponding to administration time close to incision was 4 minutes before incision (95% one-sided CI, 0-18 minutes). The model suggested optimal timing would result in an 11.3% reduction in the primary infection end point. CONCLUSIONS: Risk of infectious complications decreased as antibiotic administration moved closer to incision time. These data suggest an opportunity to reduce infections by 11.3% by targeting initial antibiotic administration closer to incision.

Reduction in pediatric identification band errors: a quality collaborative.

BACKGROUND AND OBJECTIVE: Accurate and consistent placement of a patient identification (ID) band is used in health care to reduce errors associated with patient misidentification. Multiple safety organizations have devoted time and energy to improving patient ID, but no multicenter improvement collaboratives have shown scalability of previously successful interventions. We hoped to reduce by half the pediatric patient ID band error rate, defined as absent, illegible, or inaccurate ID band, across a quality improvement learning collaborative of hospitals in 1 year. METHODS: On the basis of a previously successful single-site intervention, we conducted a self-selected 6-site collaborative to reduce ID band errors in heterogeneous pediatric hospital settings. The collaborative had 3 phases: preparatory work and employee survey of current practice and barriers, data collection (ID band failure rate), and intervention driven by data and collaborative learning to accelerate change. RESULTS: The collaborative audited 11377 patients for ID band errors between September 2009 and September 2010. The ID band failure rate decreased from 17% to 4.1% (77% relative reduction). Interventions including education of frontline staff regarding correct ID bands as a safety strategy; a change to softer ID bands, including "luggage tag" type ID bands for some patients; and partnering with families and patients through education were applied at all institutions. CONCLUSIONS: Over 13 months, a collaborative of pediatric institutions significantly reduced the ID band failure rate. This quality improvement learning collaborative demonstrates that safety improvements tested in a single institution can be disseminated to improve quality of care across large populations of children.

Appraising the evidence for avoiding lotions or topical agents prior to radiation therapy.

This project aimed to determine whether avoiding the use of lotions or topical agents for four hours prior to radiation therapy is supported by evidence. A comprehensive literature review, interviews with clinical experts, benchmarking with international cancer centers, and consultation with professional nursing organizations were conducted. Results showed limited evidence as well as variation in practice.

Examining telephone calls in ambulatory oncology.

A large component of ambulatory oncology practice is management of telephone calls placed to and from the practice between outpatient appointments, but they are not a reimbursable service, they require staff resources, and they place an unpredictable demand on workload. In this study, telephone calls were examined at a private medical oncology practice to define telephone call volume and distribution in an active ambulatory oncology practice, describe the callers and reasons for calls, and examine any differences in call volume by practice characteristics.

A randomized double-blind comparison of a morphine-fentanyl combination vs. morphine alone for patient-controlled analgesia following bowel surgery.

An ideal patient-controlled analgesia (PCA) opioid would have both a rapid onset and a long duration of action, attributes, which are not available in currently existing opioids including morphine, the most widely used agent. A mixture of rapid onset and long-acting opioids may potentially achieve both these qualities. In a randomized, double-blind study, we compared a fentanyl-morphine combination with morphine alone for PCA, in 54 patients undergoing bowel surgery. The combination solution was prepared according to a 1:75 fentanyl to morphine potency ratio. The mixture contained fentanyl 13.33 mug/mL and morphine 1 mg/mL. The morphine alone solution contained 2 mg/mL. Patients were randomly allocated to one of the regimens and were then evaluated 4 times during the first 48 hours following surgery. Time to effect, visual analog pain scores, opioid consumption, demands, deliveries, and side effects on an opioid-related symptom distress scale were recorded. Groups were well matched for age, weight, and sex. There were no significant differences between groups in time to effect, PCA usage, pain scores or side effects other than the occurrence of nausea, which was lower for the combination group in 1 visit. Further studies are needed to explore the potential of different potency ratios and opioid combinations to achieve rapid and long-lasting pain control.

The association between maltreatment and obesity among preschool children.

OBJECTIVE: To determine whether child maltreatment is associated with obesity in preschool children. METHODS: Data were obtained from the Fragile Families and Child Wellbeing Study, a birth cohort study of 4898 children born between 1998 and 2000 in 20 large US cities. At 3 years of age, 2412 of these children had their height and weight measured, and mothers answered items on the Parent-Child Conflict Tactics Scales about three types of child maltreatment--neglect, corporal punishment, and psychological aggression. The frequency of each type of maltreatment behavior in the prior year was analyzed using categories--ever/never for neglect and quintiles for the other two types of maltreatment. Child obesity was defined as measured body mass index (kg/m(2)) > or =95th percentile. RESULTS: Eighteen percent of the children were obese, and the prevalence of any episode of neglect, corporal punishment, and psychological aggression was 11%, 84%, and 93%, respectively. The odds of obesity were increased in children who had experienced neglect (odds ratio 1.56, 95% confidence interval, 1.14-2.14), after controlling for the income and number of children in the household, the mothers' race/ethnicity, education, marital status, body mass index, prenatal smoking, and age, and the children's sex and birth weight. Neither the frequency of corporal punishment nor psychological aggression was associated with an increased risk of obesity. CONCLUSIONS: In a sample of preschool children from 20 large US cities, maternal self-report of neglectful behavior was associated with an increased risk of childhood obesity, after controlling for birth weight, maternal obesity, and multiple socioeconomic factors.

Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children.

OBJECTIVES: We sought to determine if the prevalence of depression and anxiety in mothers and the prevalence of behavior problems in preschool-aged children are more common when mothers report being food insecure. METHODS: A cross-sectional survey of 2870 mothers of 3-year-old children was conducted in 2001-2003 in 18 large US cities. On the basis of the adult food-security scale calculated from the US Household Food Security Survey Module, mothers were categorized into 3 levels: fully food secure, marginally food secure, and food insecure. The 12-month prevalence in mothers of a major depressive episode and generalized anxiety disorder was assessed by the Composite International Diagnostic Interview-Short Form. A child behavior problem in > or = 1 of 3 domains (aggressive, anxious/depressed, or inattention/hyperactivity) was based on the Child Behavior Checklist. RESULTS: Seventy-one percent of the respondents were fully food secure, 17% were marginally food secure, and 12% were food insecure. After adjustment for sociodemographic factors plus maternal physical health, alcohol use, drug use, prenatal smoking, and prenatal physical domestic violence, the percentage of mothers with either major depressive episode or generalized anxiety disorder increased with increasing food insecurity: 16.9%, 21.0%, and 30.3% across the 3 levels. Among children, after further adjustment for maternal major depressive episode and generalized anxiety disorder, the percentage with a behavior problem also increased with increasing food insecurity: 22.7%, 31.1%, and 36.7%. CONCLUSIONS: Mental health problems in mothers and children are more common when mothers are food insecure, a stressor that can potentially be addressed by social policy.