[Latent safety threats in a pediatric emergency department: Using in situ simulation to test a new trauma room concept]. / Latente Sicherheitsmängel in einer pädiatrischen Notaufnahme: Testung eines neuen Schockraumkonzepts mithilfe von In-situ-Simulation.

INTRODUCTION: Structured emergency room concepts have been shown to contribute to patient safety. Until now there has been no uniform emergency room concept for critically ill and seriously injured children and adolescents in the emergency room at the Altona Children's Hospital in Hamburg. This concept has been newly developed in interdisciplinary cooperation and includes the use of new clinical premises as well as new responsibilities and team compositions. The introduction of new processes and rooms for handling emergencies is associated with a risk of overlooking latent safety deficiencies or detecting them only after the process has been implemented. This may have a direct impact on patient safety. Before moving to new clinical premises, in situ simulation can be helpful to identify and to resolve latent safety threats in advance. Therefore, this method was chosen to test the newly created emergency room concept in the future emergency room at the Altona Children's Hospital. METHODS: Two in situ simulations were carried out in the future real emergency room. Latent safety threats detected by the observation team and the participants (medical and nursing staff of the Altona Children's Hospital from the departments of pediatric surgery, traumatology, orthopedics, pediatrics, anesthesia, intensive care medicine, radiology, emergency medicine) were collected using free text notes after the simulations and evaluated retrospectively. In order to better deal with these latent safety threats, the observations were classified into different categories: working environment (e.g., lack of equipment, unfavorable positioning of material), process (e.g., lack of defined responsibilities in the team) and other safety threats that did not fall into one of the two categories defined. RESULTS: A total of 51 latent safety threats were identified during the two in situ simulations. Of these, 22 (43.1%) were assigned to the "working environment" category, 20 (39.2%) to the "process" category and 9 (17.7%) to the "other safety threats" category. Of the latent safety threats identified, 46 (90.2 %) could be resolved before the emergency room was put into operation. For the non-recoverable safety threats, safety concepts were developed in order to further minimize the risk of patient hazard. DISCUSSION: With the help of this study, it could be shown that the implementation of in situ simulation before the commissioning of new clinical premises and the introduction of new processes can contribute to the detection of latent safety threats in an interdisciplinary German pediatric emergency department.

An Initiative to Decrease Laboratory Testing in a NICU.

BACKGROUND AND OBJECTIVES: Laboratory testing is performed frequently in the NICU. Unnecessary tests can result in increased costs, blood loss, and pain, which can increase the risk of long-term growth and neurodevelopmental impairment. Our aim was to decrease routine screening laboratory testing in all infants admitted to our NICU by 20% over a 24-month period. METHODS: We designed and implemented a multifaceted quality improvement project using the Institute for Healthcare Improvement's Model for Improvement. Baseline data were reviewed and analyzed to prioritize order of interventions. The primary outcome measure was number of laboratory tests performed per 1000 patient days. Secondary outcome measures included number of blood glucose and serum bilirubin tests per 1000 patient days, blood volume removed per 1000 patient days, and cost. Extreme laboratory values were tracked and reviewed as balancing measures. Statistical process control charts were used to track measures over time. RESULTS: Over a 24-month period, we achieved a 26.8% decrease in laboratory tests performed per 1000 patient days (∽51 000 fewer tests). We observed significant decreases in all secondary measures, including a decrease of almost 8 L of blood drawn and a savings of $258 000. No extreme laboratory values were deemed attributable to the interventions. Improvement was sustained for an additional 7 months. CONCLUSIONS: Targeted interventions, including guideline development, dashboard creation and distribution, electronic medical record optimization, and expansion of noninvasive and point-of-care testing resulted in a significant and sustained reduction in laboratory testing without notable adverse effects.

Comparison of Manual and Automated Sepsis Screening Tools in a Pediatric Emergency Department.

OBJECTIVES: To compare the performance and test characteristics of an automated sepsis screening tool with that of a manual sepsis screen in patients presenting to a pediatric emergency department (ED). METHODS: We conducted a retrospective cohort study of encounters in a pediatric ED over a 2-year period. The automated sepsis screening algorithm replaced the manual sepsis screen 1 year into the study. A positive case was defined as development of severe sepsis or septic shock within 24 hours of disposition from the ED. We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratios with 95% confidence intervals (CIs) for each. RESULTS: There were 122 221 ED encounters during the study period and 273 cases of severe sepsis. During year 1 of the study, the manual screen was performed in 8910 of 61 026 (14.6%) encounters, resulting in the following test characteristics: sensitivity of 64.6% (95% CI 54.2%-74.1%), specificity of 91.1% (95% CI 90.5%-91.7%), PPV of 7.3% (95% CI 6.3%-8.5%), and NPV of 99.6% (95% CI 99.5%-99.7%). During year 2 of the study, the automated screen was performed in 100% of 61 195 encounters, resulting in the following test characteristics: sensitivity of 84.6% (95% CI 77.4%-90.2%), specificity of 95.1% (95% CI 94.9%-95.2%), PPV of 3.7% (95% CI 3.4%-4%), and NPV of 99.9% (95% CI 99.9%-100%). CONCLUSIONS: An automated sepsis screening algorithm had higher sensitivity and specificity than a widely used manual sepsis screen and was performed on 100% of patients in the ED, ensuring continuous sepsis surveillance throughout the ED stay.

Decision-Making in the Era of New Medical Technologies in Pediatric Hematology-Oncology: The Death of Palliative Care?

BACKGROUND: Recent advances in immunology, genomics, and cellular therapy have opened numerous therapeutic possibilities in pediatric hematology-oncology, generating new hope in poor prognosis situations. How decisions are made when it comes to treatments and aims needs to be explored in this new technologic context. In particular, their impact on the gold standard of early referral to palliative care must be assessed. MATERIALS AND METHODS: Stemming from an ethnographic study combining semistructured interviews and observations carried out in a hematopoietic stem cell transplant unit in a Montréal Pediatric Hospital, we discuss the decision-making process when a patient faces poor prognosis. RESULTS AND DISCUSSION: Although health care providers individually envisioned that palliative care may be the best course of action for patients receiving emergent therapy, they remained collectively in the curative mode. The intricate relationship between science, hope, caregiver, and care receiver sustains this perspective even when (near) death is the probable outcome. When proven treatment fails, emerging therapeutic possibilities offer new hope that can delay the referral to the palliative care team.

Antifungal stewardship in a tertiary care paediatric hospital: the PROAFUNGI study.

BACKGROUND: The increasing use of antifungal drugs (AF) in children and the concern for related adverse events and costs has led to the development of specific AF stewardship programmes (AFS). Studies in adult patients have shown improvements in AF prescription and usage after implementation, but paediatric data are scant. The aim of this PROAFUNGI study was to describe the use and appropriateness of AF in a high complexity paediatric centre. METHODS: Observational, prospective, single-centre, modified point-prevalence study (11 surveys, July-October 2018), including paediatric (< 18 years) patients receiving at least one systemic AF. Prescriptions were evaluated by the AFS team. RESULTS: The study included 119 prescriptions in 55 patients (53% males, median age 8.7 years [IQR 2.4-13.8]). The main underlying condition was cancer (45.5% of patients; HSCT in 60% of them); and the first indication for AF was prophylaxis (75 prescriptions, 63.2%). Liposomal amphotericin B was used most commonly (46% prescriptions), mainly as prophylaxis (75%). Among the 219 evaluations, 195 (89%) were considered optimal. The reason for non-optimal prescriptions was mostly lack of indication (14/24), especially in critical patients with ventricular assist devices. The use of AF without paediatric approval accounted for 8/24 inappropriate prescriptions. CONCLUSIONS: A high rate of AF appropriateness was found for the children's hospital as a whole, in relation with a well-established AFS. Nonetheless, the identification of specific areas of improvement should guide future actions of the AFS team, which will focus mainly on prophylaxis in critically ill patients receiving circulatory assistance and the use of non-approved drugs in children.

Standardized Order Set Exhibits Surgeon Adherence to Pain Protocol in Pediatric Adenotonsillectomy.

OBJECTIVES/HYPOTHESIS: To produce a sustained reduction in opioid prescriptions in patients <5 years of age undergoing T&A through utilization of standardized algorithms and electronic health record (EHR) automation tools. STUDY DESIGN: Prospective quality improvement initiative. METHODS: Plan-do-study-act (PDSA) methodology was used to design an age-based postoperative pain regimen in which children <5 years of age received a non-opioid pain regimen, and option to prescribe oxycodone for additional pain relief was given for children >5 years of age. Standardized discharge instructions and automated, age-specific order sets were created to facilitate adherence. Rate of discharge opioid prescription was monitored and balanced against post-discharge opioid prescriptions and returns to the emergency department (ED). RESULTS: In children <5 years of age undergoing T&A, reduction in opioid prescription rates from 65.9% to 30.9% after initial implementation of the order set was noted. Ultimately, reduction of opioid prescribing rates to 3.7% of patients was noted after pain-regimen consensus and EHR order set implementation. Opioid prescriptions in patients >5 years of age decreased from 90.6% to 58.1% initially, and then down 35.9% by the last time point analyzed. Requests for outpatient opioid prescriptions did not increase. There was no significant change in returns to the emergency ED for pain management, or in the number opioids prescribed when patients returned to the ED. CONCLUSIONS: Iterative cycles of improvement utilizing standardized pain management algorithms and EHR tools were effective means of producing a sustained reduction in opioid prescriptions in postoperative T&A patients. Such findings suggest a framework for similar interventions in other pediatric otolaryngology settings. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2337-E2343, 2021.

Cross-cultural adaptation and validation of the montreal children's hospital feeding scale into brazilian portuguese / Adaptação transcultural e validação da montreal children's hospital feeding scale para o português falado no brasil

ABSTRACT Objective: To cross-culturally adapt and validate the Montreal Children's Hospital Feeding Scale (MCH-FS) into Brazilian Portuguese. Methods: The MCH-FS, originally validated in Canada, was validated in Brazil as Escala Brasileira de Alimentação Infantil (EBAI) and developed according to the following steps: translation, production of the Brazilian Portuguese version, testing of the original and the Brazilian Portuguese versions, back-translation, analysis by experts and by the developer of the original questionnaire, and application of the final version. The EBAI was applied to 242 parents/caregivers responsible for feeding children from 6 months to 6 years and 11 months of age between February and May 2018, with 174 subjects in the control group and 68 ones in the case group. The psychometric properties evaluated were validity and reliability. Results: In the case group, 79% of children were reported to have feeding difficulties, against 13% in the control group. The EBAI had good internal consistency (Cronbach's alpha=0.79). Using the suggested cutoff point of 45, the raw score discriminated between cases and controls with a sensitivity of 79.4% and specificity of 86.8% (area under the ROC curve=0.87). Conclusions: The results obtained in the validation process of the EBAI demonstrate that the questionnaire has adequate psychometric properties and, thus, can be used to identify feeding difficulties in Brazilian children from 6 months to 6 years and 11 months of age.

RESUMO Objetivo: Realizar a adaptação transcultural e a validação da escala Montreal Children's Hospital Feeding Scale (MCH-FS) para a língua portuguesa falada no Brasil. Métodos: A MCH-FS, originalmente validada no Canadá, foi validada no Brasil como Escala Brasileira de Alimentação Infantil (EBAI) e desenvolvida a partir das seguintes etapas: tradução, montagem da versão em português brasileiro, teste da versão em inglês e da versão em português brasileiro, retrotradução, análise por experts e autora do questionário original e aplicação da versão final em estudo. A EBAI foi aplicada em 242 pais/cuidadores responsáveis pela alimentação de crianças de seis meses a seis anos e 11 meses de idade no período de fevereiro a maio de 2018, sendo 174 no grupo controle e 68 no grupo dos casos. As propriedades psicométricas avaliadas foram validade e confiabilidade. Resultados: No grupo dos casos, 79% dos pais/cuidadores relataram dificuldades alimentares, e no grupo controle, 13%. A EBAI apresentou boa consistência interna (alfa de Cronbach=0,79). Utilizando-se o ponto de corte sugerido de 45, o escore bruto (raw score) diferenciou casos de controles com sensibilidade de 79,4% e especificidade de 86,8% (área sob a curva ROC=0,87). Conclusões: Os resultados obtidos na validação da EBAI evidenciaram medidas psicométricas adequadas. Portanto, a escala pode ser utilizada na identificação de dificuldades alimentares em crianças brasileiras de seis meses a seis anos e 11 meses idade.

Prevalence of neutralizing antibodies against poliovirus 1, 2, and 3 in healthcare professionals aged 20-50 years / Prevalência de anticorpos neutralizantes contra poliovírus 1, 2 e 3 em profissionais de saúde de 20 a 50 anos de idade

ABSTRACT Objective: To describe the prevalence of neutralizing antibodies against poliovirus (PV1, PV2, and PV3) in blood samples of healthcare professionals aged 20 to 50 years. Methods: Health professionals who serve children at Darcy Vargas Children's Hospital and the Department of Pediatrics of Irmandade da Santa Casa de São Paulo. The sample size was calculated at 323 participants. The Mantel-Haenszel chi-square was used to verify differences between groups. The neutralization reaction detected human poliovirus antibodies. For susceptible individuals, vaccination with the inactivated+triple acellular polio vaccine was performed, and neutralizing antibodies were re-dosed after one week. Results: 333 professionals were studied - 92.8% were immune to poliovirus 1, 86.5% to poliovirus 2, and 63.3% to poliovirus 3; 37% had titers less than 1:8 for any serotype, 5;1% had titers below 1:8 for all three. Vaccination with inactivated polio vaccine was performed for susceptible participants, and neutralizing antibodies were dosed after one week, showing increased titers for all polioviruses. Conclusions: Despite the detection of a significant percentage of individuals with low poliovirus antibody titer, the challenge with vaccination demonstrated immune response compatible with poliovirus immunity.

RESUMO Objetivo: Descrever a prevalência de anticorpos neutralizantes contra poliovírus (tipos 1, 2 e 3) em amostra de sangue de profissionais de saúde com idade de 20 a 50 anos. Métodos: Profissionais de saúde que atendem crianças do Hospital Infantil Darcy Vargas e do Departamento de Pediatria da Irmandade da Santa Casa de São Paulo. O tamanho da amostra foi de 323 participantes. Os anticorpos contra poliovírus humanos foram detectados pela reação de neutralização. Para os indivíduos suscetíveis, foram administradas vacina para poliomielite inativada+tríplice e nova dosagem de anticorpos neutralizantes após uma semana. Utilizou-se o teste do qui-quadrado de Mantel-Haenszel para verificar as diferenças entre os grupos. Resultados: Foram estudados 333 profissionais - 92,8% eram imunes ao poliovírus 1; 86,5%, ao poliovírus 2; 63,57%, ao poliovírus 3; 37% apresentaram títulos inferiores a 1:8 para qualquer sorotipo; 5,1% tinham títulos abaixo de 1:8 para os três. Após a vacinação dos suscetíveis, houve elevação dos títulos para todos os poliovírus. Conclusões: Apesar da detecção de percentual significativo de indivíduos com baixo título de anticorpos para poliovírus, o desafio da vacinação demonstrou resposta imune robusta compatível.

An Evidence-Based Care Protocol Improves Outcomes and Decreases Cost in Pediatric Appendicitis.

BACKGROUND: Appendicitis is a common indication for urgent abdominal surgery in the pediatric population. The postoperative management varies significantly in time to discharge and cost of care. The objective of this study was to investigate whether implementation of an evidence-based protocol after an appendectomy would lead to decreased length of stay and cost of care. METHODS: In 2014 at the Children's Hospital of Pittsburgh, an initiative to develop an evidenced-based protocol to treat appendicitis was undertaken. A work group was formed of pediatric surgeons and other important personnel to determine best practices. Treatment pathways were created. Pathways differed with recommendation on postoperative antibiotic choice and duration, diet initiation, and discharge criteria. Data were prospectively gathered from all patients (ages 0-18 y) with acute appendicitis from January 2015 to December 2016. Primary outcomes were length of stay and cost of care. Secondary outcomes were surgical site infection, readmission rate, and duration of postoperative antibiotics. RESULTS: Among the 1289 patients, 481 patients were in the preprotocol cohort and 808 patients were in the postprotocol cohort. 27% of patients had an intraoperative diagnosis of complicated appendicitis. There was a significantly shorter length of stay in the postprotocol cohort (P < 0.001). Median costs for the whole cohort decreased 0.6% and 24.6% for patients with complicated appendicitis after protocol initiation (P < 0.01). CONCLUSIONS: This study has demonstrated that introduction of an evidence-based clinical care protocol for pediatric patients with appendicitis leads to shorter hospital stay and decreased hospital costs.

The Acceptability and Impact of the Xploro Digital Therapeutic Platform to Inform and Prepare Children for Planned Procedures in a Hospital: Before and After Evaluation Study.

BACKGROUND: There is increasing interest in finding novel approaches to improve the preparation of children for hospital procedures such as surgery, x-rays, and blood tests. Well-prepared and informed children have better outcomes (less procedural anxiety and higher satisfaction). A digital therapeutic (DTx) platform (Xploro) was developed with children to provide health information through gamification, serious games, a chatbot, and an augmented reality avatar. OBJECTIVE: This before and after evaluation study aims to assess the acceptability of the Xploro DTx and examine its impact on children and their parent's procedural knowledge, procedural anxiety, and reported experiences when attending a hospital for a planned procedure. METHODS: We used a mixed methods design with quantitative measures and qualitative data collected sequentially from a group of children who received standard hospital information (before group) and a group of children who received the DTx intervention (after group). Participants were children aged between 8 and 14 years and their parents who attended a hospital for a planned clinical procedure at a children's hospital in North West England. Children and their parents completed self-report measures (perceived knowledge, procedural anxiety, procedural satisfaction, and procedural involvement) at baseline, preprocedure, and postprocedure. RESULTS: A total of 80 children (n=40 standard care group and n=40 intervention group) and their parents participated in the study; the children were aged between 8 and 14 years (average 10.4, SD 2.27 years) and were attending a hospital for a range of procedures. The children in the intervention group reported significantly lower levels of procedural anxiety before the procedure than those in the standard group (two-tailed t63.64=2.740; P=.008). The children in the intervention group also felt more involved in their procedure than those in the standard group (t75=-2.238; P=.03). The children in the intervention group also reported significantly higher levels of perceived procedural knowledge preprocedure (t59.98=-4.892; P=.001) than those in the standard group. As for parents, those with access to the Xploro intervention reported significantly lower levels of procedural anxiety preprocedure than those who did not (t68.51=1.985; P=.05). During the semistructured write and tell interviews, children stated that they enjoyed using the intervention, it was fun and easy to use, and they felt that it had positively influenced their experiences of coming to the hospital for a procedure. CONCLUSIONS: This study has shown that the DTx platform, Xploro, has a positive impact on children attending a hospital for a procedure by reducing levels of procedural anxiety. The children and parents in the intervention group described Xploro as improving their experiences and being easy and fun to use.

Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

BACKGROUND: Common cause analysis of hospital safety events that involve radiology can identify opportunities to improve quality of care and patient safety. OBJECTIVE: To study the most frequent system failures as well as key activities and processes identified in safety events in an academic children's hospital that underwent root cause analysis and in which radiology was determined to play a contributing role. MATERIALS AND METHODS: All safety events involving diagnostic or interventional radiology from April 2013 to November 2018, for which the hospital patient safety department conducted root cause analysis, were retrospectively analyzed. Pareto charts were constructed to identify the most frequent modalities, system failure modes, key processes and key activities. RESULTS: In 19 safety events, 64 sequential interactions were attributed to the radiology department by the patient safety department. Five of these safety events were secondary to diagnostic errors. Interventional radiology, radiography and diagnostic fluoroscopy accounted for 89.5% of the modalities in these safety events. Culture and process accounted for 55% of the system failure modes. The three most common key processes involved in these sequential interactions were diagnostic (39.1%) and procedural services (25%), followed by coordinating care and services (18.8%). The two most common key activities were interpreting/analyzing (21.9%) and coordinating activities (15.6%). CONCLUSION: Proposing and implementing solutions based on the analysis of a single safety event may not be a robust strategy for process improvement. Common cause analyses of safety events allow for a more robust understanding of system failures and have the potential to generate more specific process improvement strategies to prevent the reoccurrence of similar errors. Our analysis demonstrated that the most common system failure modes in safety events attributed to radiology were culture and process. However, the generalizability of these findings is limited given our small sample size. Aligning with other children's hospitals to use standard safety event terminology and shared databases will likely lead to greater clarity on radiology's direct and indirect contributions to patient harm.

Optimizing Resources in Children's Surgical Care: An Update on the American College of Surgeons' Verification Program.

Surgical procedures are performed in the United States in a wide variety of clinical settings and with variation in clinical outcomes. In May 2012, the Task Force for Children's Surgical Care, an ad hoc multidisciplinary group comprising physicians representing specialties relevant to pediatric perioperative care, was convened to generate recommendations to optimize the delivery of children's surgical care. This group generated a white paper detailing the consensus opinions of the involved experts. Following these initial recommendations, the American College of Surgeons (ACS), Children's Hospital Association, and Task Force for Children's Surgical Care, with input from all related perioperative specialties, developed and published specific and detailed resource and quality standards designed to improve children's surgical care (https://www.facs.org/quality-programs/childrens-surgery/childrens-surgery-verification). In 2015, with the endorsement of the American Academy of Pediatrics (https://pediatrics.aappublications.org/content/135/6/e1538), the ACS established a pilot verification program. In January 2017, after completion of the pilot program, the ACS Children's Surgery Verification Quality Improvement Program was officially launched. Verified sites are listed on the program Web site at https://www.facs.org/quality-programs/childrens-surgery/childrens-surgery-verification/centers, and more than 150 are interested in verification. This report provides an update on the ACS Children's Surgery Verification Quality Improvement Program as it continues to evolve.

Closing the gap in care of blunt solid organ injury in children.

INTRODUCTION: Cross-sectional data of pediatric blunt solid organ injury demonstrates higher rates of nonoperative management and shorter lengths of stay (LOSs) in pediatric trauma centers (PTCs) versus adult trauma centers (ATCs) or dual trauma centers (DTCs). Recent iterations of guidelines (McVay 2008, J Pediatr Surg 2008;43(6):1072-1076 J Trauma Acute Care Surg 2015;79(4):683-693) have emphasized physiologic parameters rather than injury grade in clinical decision making, improving resource allocation and decreasing LOS. We sought to evaluate how these guidelines have influenced care. METHODS: The National Trauma Data Bank (2007-2016) was queried for isolated spleen and liver injuries in patients younger than 19 years. Linear regression, odds ratio (OR), and χ test were used to determine significance between operative intervention or LOS among different trauma center types and grade of injury. RESULT: A total of 55,036 blunt spleen or liver injuries were identified. Although operative rates decreased in ATCs over time (p = 0.037), patients treated at ATCs or DTCs continued to demonstrate higher ORs of operative intervention (OR, 4.43 and 2.88, respectively) compared with PTCs. Mean LOS decreased by 1.52 (p < 0.001), 0.49 (p = 0.26), and 1.31 (p = 0.05) days at ATC, DTC, and PTC to 6.43, 6.68, and 5.16 days. Improvement in LOS for ATCs was distributed across injury Grades I, II, and IV, while there was no correlation among PTCs for injury grade. CONCLUSION: Despite more than a decade of guidelines in pediatric solid organ injury supporting nonoperative management and accelerated discharge pathways based on physiologic parameters, rates of operative intervention remain much higher in ATCs versus PTCs, and all centers appear to fall short of consensus guidelines for discharge. LEVEL OF EVIDENCE: Care management study, level IV.

A nurse-led paediatric oncology fast-track clinic proves a successful ambulatory intervention for patients.

AIM: To assess the impact of a pilot nurse-led paediatric oncology fast-track clinic (OFTC) for complications and side effects following chemotherapy within a paediatric tertiary hospital. METHODS: Prospective clinical data from the first 100 patients seen in the OFTC were compared with retrospective data of oncology patient presentations to the emergency department (ED) (over a 1-year period, n = 196) who would have been eligible for review in the OFTC. Parent and patient satisfaction of clinical care were also assessed via surveys pre- and post-OFTC implementation. RESULTS: Analysis which achieved statistical difference was a reduction in the number of blood tubes taken in OFTC (average 1.9 for those discharged from clinic, 2.9 for those admitted from clinic) in comparison to those seen in the ED (average 3.2) (p = 0.0027). The average number of interventions per patient seen in the ED were 2.1 (standard deviation 1.64) compared with 1.7 (standard deviation 1.55) interventions per patient seen in the OFTC, and who were not admitted following review. This result approached statistical significance with p = 0.0963. Other results which did not meet statistical significance included a reduction in treatment times, hospital admissions and medical oncology reviews. CONCLUSION: Our pilot study implementing an OFTC for the triage and assessment of chemotherapy-related complications has proven successful from an operational and consumer perspective. The clinic improved care by ensuring expedited review, more streamlined interventions, and less overall hospital admissions. The improvements in efficiency were also mirrored by increased parent and patient satisfaction.

Investigating transmission of Mycobacterium abscessus amongst children in an Australian cystic fibrosis centre.

BACKGROUND: Mycobacterium abscessus is an emerging pathogen in cystic fibrosis (CF) lung disease. Hospital transmission of M. abscessus has been described. This paper details the investigation into possible cross-transmission of M. abscessus locally at our paediatric hospital CF centre, and the subsequent infection control response. METHODS: Whole genome sequencing (WGS) of M. abscessus respiratory isolates with epidemiological linkage analysis using hospital electronic medical records. RESULTS: 6.7% (22/328) of CF patients had M. abscessus isolated from respiratory specimens. WGS revealed a cluster of three patients with genomically related isolates that differed by <7 single nucleotide polymorphisms (SNPs), suggesting a shared recent ancestor and probable cross-transmission. Epidemiological investigation revealed multiple potential crossovers between patients with genomically similar M. abscessus isolates. CONCLUSIONS: Cross-infection of NTM occurs in CF hospital patients. Hospital infection control practices should be upgraded to reflect this. Consensus is needed between centres.

Influência de fatores epidemiológicos no seguimento e aparecimento de problemas puerperais / Influencia de factores epidemiológicos en el seguimiento y la aparición de problemas puerperales / Influence of epidemiological factors on follow-up and appearance of puerperal problems

Objetivo descrever a influência de fatores epidemiológicos para o seguimento puerperal e para o aparecimento de problemas de saúde em região coberta pela Rede Mãe Paranaense. Método pesquisa descritiva, quantitativa, com 280 puérperas de municípios da nona Regional de Saúde do Paraná, realizada no segundo semestre de 2017 e primeiro de 2018, organizada em duas etapas: no alojamento conjunto de maternidades e nos domicílios, após seis meses do parto. Resultados a consulta na primeira semana após o parto foi realizada por 51,1% das puérperas, e com 42 dias 76,8%. Baixa idade e escolaridade foram associadas a não realização das consultas. Identificou-se 20,7% de puérperas com problemas clínicos, 53,2% com sintomas emocionais, e aproximadamente 10% com sintomas depressivos e pensamentos suicidas. Conclusão fatores epidemiológicos têm influência para a adesão insatisfatória de consultas puerperais, mas não para o aparecimento de problemas de saúde no puerpério.

Objetivo describir la influencia de los factores epidemiológicos para el seguimiento puerperal y la aparición de problemas de salud en la región cubierta por la Red Mãe Paranaense. Método estudio descriptivo, cuantitativo, con 280 puérperas de municipios de la novena Salud Regional de Paraná, que tuvo lugar en la segunda mitad de 2017 y primera mitad de 2018, organizada en dos pasos: en el alojamiento conjunto de las maternidades y en los hogares, seis meses después del nacimiento. Resultados la consulta en la primera semana después del parto fue realizada por el 51,1% de las puérperas, y con 42 días, por el 76,8%. Baja edad y escolaridad se asociaron con la no realización de consultas. Se identificó el 20,7% de puérperas con problemas clínicos, el 53,2% con síntomas emocionales, y aproximadamente el 10% con síntomas de depresión y pensamientos suicidas. Conclusión factores epidemiológicos influyen en la adherencia deficiente de consultas puerperales, pero no en la aparición de problemas de salud en el puerperio.

Objective to describe the influence of epidemiological factors on the puerperal follow-up and on the emergence of health problems in the region covered by the Mãe Paranaense Network. Method descriptive, quantitative research, with 280 puerperal women from counties of the ninth Health Region of Paraná, held in the second half of 2017 and first half of 2018, organized in two steps: in the rooming-in care of maternities and in the homes, six months after the birth. Results the appointment in the first week after delivery was performed by 51.1% of the puerperal women, and with 42 days, by 76.8%. Low age and schooling were associated with the non-completion of appointments. There were 20.7% of puerperal women with clinical problems, 53.2% with emotional symptoms, and approximately 10% with depressive symptoms and suicidal thoughts. Conclusion epidemiological factors influence the poor adherence to puerperal appointments, but not the emergence of health problems in the puerperium.

Parents' and healthcare professionals' perceptions of the quality of care: A PITSTOP model of caring.

BACKGROUND: Quality of care is measured by various indicators. Besides objective quantifications, it is necessary to understand the meaning of quality of care from the perspectives of patients, families, and healthcare professionals. OBJECTIVES: This study aimed to understand parents' and healthcare professionals' perceptions of the quality of care. METHODS: This was a secondary data analysis of two qualitative studies examining parents' and healthcare professionals' perceptions of caring in 2014 and 2018, respectively. Both studies took place in a children's hospital in the United States. There were 40 participants, 13 parents of children undergoing heart surgery and 27 healthcare professionals. The current study focused on parents' and healthcare professionals' viewpoints about the quality of care. RESULTS: Seven themes emerged: patient-centered care, interprofessional collaboration, team communication, safety and security, trusting relationships, optimal outcomes, and positive patient experiences. The acronym PITSTOP was developed to enable healthcare professionals to recall the elements deemed as important to the quality of care by parents and professionals. CONCLUSIONS: This study brought up a novice opinion that healthcare should be like a "pitstop," not just a "repair shop." Healthcare encounters may be brief but invaluable in helping patients and families succeed in their health promotion.

Quality Improvement of Magnetic Resonance Imaging for Musculoskeletal Infection in Children Results in Decreased Scan Duration and Decreased Contrast Use.

BACKGROUND: Magnetic resonance imaging (MRI) is a heavily utilized resource to evaluate children suspected to have a musculoskeletal infection. Complex interdisciplinary workflows are involved with decision-making with regard to indications, anesthesia, contrast use, and procedural timing relative to the scan. This study assesses the impact of a quality improvement endeavor on MRI workflows at a tertiary pediatric medical center. METHODS: A registry of consecutively enrolled children for a multidisciplinary musculoskeletal infection program identified those evaluated with MRI from 2012 to 2018. Annual MRI process improvement feedback was provided to the key stakeholders. Demographic characteristics, laboratory parameters, MRI indications, anesthesia use, MRI findings, final diagnoses, scan duration, imaging protocol, surgical intervention following MRI, and length of stay were retrospectively compared between the 3 cohorts (initial, middle, and final) representing 2-year increments to assess the impact of the initiative. RESULTS: There were 526 original MRI scans performed to evaluate 1,845 children with suspected musculoskeletal infection. Anesthesia was used in 401 children (76.2%). When comparing the initial, middle, and final study period cohorts, significant improvement was demonstrated for the number of sequences per scan (7.5 sequences for the initial cohort, 5.8 sequences for the middle cohort, and 4.6 sequences for the final cohort; p < 0.00001), scan duration (73.6 minutes for the initial cohort, 52.1 minutes for the middle cohort, and 34.9 minutes for the final cohort; p < 0.00001), anesthesia duration (94.1 minutes for the initial cohort, 68.9 minutes for the middle cohort, and 53.2 minutes for the final cohort; p < 0.00001), and the rate of contrast use (87.6% for the initial cohort, 67.7% for the middle cohort, and 26.3% for the final cohort; p < 0.00001). There was also a trend toward a higher rate of procedures under continued anesthesia immediately following the MRI (70.2% in the initial cohort, 77.8% in the middle cohort, and 84.6% in the final cohort). During the final 6-month period, the mean scan duration was 24.4 minutes, anesthesia duration was 40.9 minutes, and the rate of contrast administration was 8.5%. CONCLUSIONS: Progressive quality improvement through collaborative interdisciplinary communication and workflow redesign led to improved utilization of MRI and minimized contrast use for suspected musculoskeletal infection. There was a high rate of procedural intervention under continued anesthesia for children with confirmed musculoskeletal infection. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pediatric Anaerobic Blood Culture Practices in Industrialized Countries.

BACKGROUND: Routine anaerobic blood culture collection in febrile children is controversial, as clinicians try to account for the severe but relative infrequency of anaerobic bacteremia. Furthermore, clinical and laboratory practice variation among institutions may lead to potentially inaccurate epidemiological data. Our goal was to assess blood culture practices in pediatric patients throughout an international network of hospitals in industrialized countries. METHODS: We conducted a survey of current clinical and laboratory practice patterns in a convenience sample of international institutions participating in 6 pediatric emergency research networks in the US, Canada, Europe, Australia, and New Zealand. A lead clinician at each institution queried institutional practices from the emergency department, pediatric intensive care unit, and oncology medical directors. The microbiology director at each institution completed the laboratory survey. RESULTS: Sixty-five of 160 (41%) invited institutions participated in the survey. Routine anaerobic blood cultures are collected in 30% of emergency departments, 30% of intensive care units, and 48% of oncology wards. Reasons for restricting anaerobic culture collection included concerns regarding blood volume (51%), low pretest probability (22%), and cost-effectiveness (16%). The most common reasons institutions allow for selectively obtaining anaerobic cultures are clinical suspicion (64%) and patients who are immunosuppressed (50%). The microbiology survey showed variation in systems, although most use the BACTEC™ culture system and MALDI-TOF for organism identification. CONCLUSIONS: There is broad variation in anaerobic blood culture practices among a network of pediatric hospitals in industrialized countries.

Multi-level Intervention Program - A Quality Improvement Initiative to Decrease Central Line-Associated Bloodstream Infections in the Pediatric Acute and Hematology/Oncology Units.

INTRODUCTION: Central Venous Catheters (CVCs) are placed in pediatric patients that require frequent and/or long-term access for intravenous treatments and increase the risk for Central line-associated bloodstream infections (CLABSIs). The specific aims of the study were to evaluate adherence to the intervention components and rates of Central Line Associated Bloodstream Infections (CLABSIs) over five years. METHODS: Implementation occurred on the acute care and hematology-oncology pediatric units of a quaternary health care setting in Southern California. Adherence rates were quantified using a CVC audit sheet and CLABSI rates were obtained quarterly before, and at year 1, 2, 3, 4, 5 of implementation. RESULTS: CLABSI rates for both pediatric units decreased over the five-year period. Adherence rates were 90% to 100% on the different features of the intervention; the lowest was adherence to Patient Protective Equipment (PPE). A total of 41 incidents of hospital-acquired CLABSIs were reported the year prior to the Bug Buster Committee, which decreased steadily to 9 incidents after implementation. The quarterly CLABSI rates in the Pediatric Acute Care ranged from 2.8 to 6.6/1,000 catheter days and in Pediatric Hematology-Oncology from 2.1 to 4.3/1,000 catheter days the year prior to implementation. CONCLUSIONS: While adherence for staff remains high, parent/family adherence was low. We recommend including in the multi-level intervention, procedures targeting parent adherence such as patient education handouts, reviewing content on admission, placing signs on doors indicating PPE requirements, and promptly providing PPE to non-adherent family members.