Documentation of Sepsis in Patients Meeting Pediatric Sepsis Criteria: An Area for Improvement.

OBJECTIVE: Documentation is a critical aspect for properly evaluating a patient's medical status. In order to accurately diagnose sepsis promptly, the need for proper documentation becomes even more necessary. We conducted a retrospective chart review to assess accuracy and frequency of sepsis documentation by electronic medical records (EMR) review. The patients are children aged 0 to 18 years of age in whom the sepsis trigger tool fired in the EMR and were admitted on the inpatient floor or pediatric intensive care unit. METHODS: An EMR sepsis notification alert is currently utilized by our institution. Two pediatric intensivists reviewed the EMR charts of hospitalized, pediatric patients in whom the notification fired. The primary outcome was to identify the patients who met criteria for sepsis according to the 2005 International Pediatric Consensus Conference Guidelines. In patients who met the criteria, physician charting was inspected manually to evaluate documentation of sepsis and/or septic shock within 24 hours of meeting sepsis criteria. RESULTS: Using the 2005 International Pediatric Consensus Conference Guidelines, 359 patients met sepsis criteria. Of those, 24 (7 percent) were documented to have sepsis and/or septic shock in the EMR. Sixteen of those patients had septic shock, while the remaining eight had sepsis. CONCLUSION: Although sepsis is not uncommon, it is often not documented appropriately in electronic medical records. Hypothesized explanations include difficulty in diagnosing sepsis and using alternative diagnoses. This study demonstrates the ambiguity of the current pediatric sepsis criteria and difficulty capturing this diagnosis in the EMR.

A Narrative Review of Key Studies in Medical Education in 2021: Applying Current Literature to Educational Practice and Scholarship.

To remain at the forefront of clinical practice and pedagogy, pediatric medical educators must stay informed of the latest research. Yet familiarization with the growing body of literature in both pediatrics and medical education is a near-impossible task for the busy medical educator. The purpose of this annotated bibliography is to summarize key manuscripts in medical education published in 2021 that have the potential to significantly influence a pediatric medical educator's practice. Using a 2-staged iterative process, discrete author pairs reviewed 1599 abstracts from 16 medical education and specialty journals. In summary, 16 manuscripts were selected and grouped into the following 6 domains: assessment and feedback, USMLE Step 1 changes, communication, wellness, diversity and inclusion, and professional development. The authors provide abridged summaries and high-yield take-aways from these manuscripts that may impact educational practices in pediatrics. This year, we also provide a 6-year retrospective review of the journals that have had selected articles for this annotated bibliography since inception.

An Annotated Bibliography of Key Studies in Medical Education in 2020: Applying the Current Literature to Educational Practice and Scholarship.

Pediatric medical educators, with their multitude of responsibilities, may have difficulty staying abreast with both medical education and specialty specific medical literature. The body of medical literature is growing at an exponential rate. This annotated bibliography serves as a summary of highlighted medical education literature in the year 2020. The purpose was to identify manuscripts which have the potential to significantly influence a pediatric medical educator's practice. The authors reviewed abstracts from 14 medical education and specialty journals using a two-staged review process. Each stage of review was completed by 2 different authors. A total of 1861 abstracts were reviewed and ultimately 15 key manuscripts were identified. The authors grouped the manuscripts into 6 core domains: diversity and inclusion, faculty development, feedback, learner development, mentorship, and teaching skills. Condensed summaries of each medical education manuscript likely to influence educational practice are provided by the authors in this annotated bibliography.

Determining Social Needs for Pediatric Patients in a Sioux Falls Pediatric Clinic.

INTRODUCTION: Social adversities such as financial insecurity, poor access to healthcare, shortage of food, and housing concerns can significantly impact health, especially for pediatric patients. The American Academy of Pediatrics recommends that pediatricians address social risks and provide interventions. This is a study where a social needs assessment screening tool was implemented at a general pediatrics clinic in Sioux Falls, South Dakota, to determine the needs of patients in the community with secondary outcomes evaluating ethnic differences in social needs. METHODS: Caregivers of pediatric patients being seen for a well-child examination were asked to participate by completing a social needs assessment form. If social needs were indicated, the clinic's health coach or the integrative health therapist contacted families to address the social need with resources available in the community. RESULTS: Caregivers completed 240 forms. Sixty-eight (31 percent) of caregivers had at least one need, house utilities being the most common followed by childcare. Total number of needs was significantly affected by race and insurance status with more needs identified in American Indian and Black ethnicities and those with public insurance. CONCLUSIONS: This was a successful implementation of a social needs assessment tool at a General Pediatric clinic. Further development and implementation of screening tools is necessary to continue to determine social needs of patients.

An Annotated Bibliography of Key Studies in Medical Education in 2019: Applying the Current Literature to Educational Practice and Scholarship.

Pediatric medical educators have the dual challenge of remaining up-to-date in the field of pediatrics and in the field of medical education. Due to the volume of information published in these 2 fields it can be nearly impossible to remain current in both fields of practice. To facilitate interpretation of the most recent medical education research, the authors conducted an annotated bibliography of medical education literature published in 2019. The purpose of this annotated bibliography was to identify manuscripts which had the potential to significantly influence a pediatric educator's practice. Using a 2-staged review process, the authors reviewed abstracts from 13 medical education and specialty journals. All reviews were independently completed by 2 different reviewers for each journal in both stages. A total of 4700 abstracts were reviewed and 17 key manuscripts were identified. The authors grouped the key manuscripts into 6 core themes: bedside teaching, learning climate, bias, learner autonomy, learner in trouble, and resident competency. This annotated bibliography provides the authors' condensed summary of the medical education manuscripts most likely to influence educational practices for the busy pediatric medical educator.

High School Day Camp Provides Insight into the Career Path and Recruitment of Future Physicians.

A physician shortage is predicted within the next 10 years in the U.S. Multiple obstacles may prevent students from choosing a career as a medical doctor including understanding of the career path. Minimizing this shortage and improving physician recruitment are being pursued. One endeavor is to address medical careers for students at the high school level. A one-day camp for high school students with an interest in a career as a physician was designed to minimize these obstacles and improve understanding of the physician career path. The camp comprised morning informational sessions with panels of undergraduate students, medical students, residents, and attending physicians. The afternoon session included hands-on activities related to physician training. Pre-camp and post-camp surveys were administered to obtain demographic information, interest level in practicing medicine, impact of the camp on understanding of career path, and the camp's influence on student comprehension of the daily routine for a physician. Results from the surveys show a significant benefit in increasing students' knowledge of the physician workday and the path to becoming a physician. Further considerations for this camp include establishing a mentorship program for high school students, reaching out to underrepresented groups in healthcare, and encouraging participation from rural areas. The camp was established through the Sioux Falls, South Dakota, local Women in Medicine and Sciences (WIMS) chapter. It is now an annual event, continuing to benefit South Dakota high school students with interests in medicine.

Learner Preference of Schedule Type Improves Engagement of Pediatric Residents: Results of a Mixed-Methods Analysis.

OBJECTIVE: Determine whether a call or shift schedule is better for acquiring optimal knowledge and professionalism, while limiting fatigue for pediatric residents during the pediatric intensive care unit (PICU) rotation in a small residency program. METHODS: This was a prospective, randomized, crossover, mixed-methods study in which pediatric residents were randomized to either a call or shift schedule during their PICU rotation. Attentiveness, bedside care, perceived knowledge, and professionalism were assessed by the resident participants, attending physicians, and nursing staff. Epworth Sleepiness Scale determined the level of resident fatigue. Statistical analysis utilized a t test of unequal variances. Two focus groups were conducted of resident non-participants and participants. Graduated resident participants and non-participants were surveyed via anonymous e-mail responses. RESULTS: Thirty residents participated in the study and twenty residents were surveyed and participated in a focus group. No major differences were detected between each participating group, whether assigned to a call or shift schedule in regard to perceived knowledge, professionalism, or fatigue. Overall themes from qualitative analysis identified advantages and disadvantages for both work schedules. Participants recognized a learner preference for schedule type depending on level of training, suggesting a shift schedule for junior residents and a call schedule for senior residents. CONCLUSIONS: There is no difference between the call or shift schedule in regard to residents' perceived knowledge, professionalism, and fatigue. Participants expressed learner preferences for one schedule over the other, recommending the shift schedule during the PGY-2 year and the call schedule during the PGY-3 year.

Necessity of Intracranial Imaging in Infants and Children With Macrocephaly.

BACKGROUND: Macrocephaly is frequently encountered in pediatrics and often leads to imaging. There are no recommendations from the American Academy of Pediatrics or the American College of Radiology providing imaging guidelines for macrocephaly. The goal of this study is to identify risk factors for pathologic macrocephaly and to aid the clinician in identifying patients that would benefit from imaging. METHODS: We conducted a medical record review throughout a multistate health care system, Sanford Health, from January 1, 2012 to December 31, 2016. Patients with macrocephaly were identified by problem list in children aged less than 36 months. Data collection included basic demographics, imaging modality, developmental delay, prematurity, seizures, focal neurological symptoms, family history of macrocephaly, sedation used, and sedation complications. RESULTS: A total of 169 patients were included in the analysis. Imaging modalities included 39 magnetic resonance imagings (23.1%), 47 cranial computed tomographies (27.8%), and 83 head ultrasounds (49.1%). Imaging results demonstrated 13 abnormal studies with five of those studies being abnormal with high clinical yield. Patients with abnormal studies were more likely to have developmental delay (P = 0.04) or neurological symptoms (P = 0.015). Positive family history of macrocephaly was predictive of normal imaging (P = 0.004). There were no sedation complications. CONCLUSIONS: Intracranial imaging does not appear to be necessary in children with no risk factors and or a positive family history of macrocephaly. Risk factors such as developmental delay or neurological symptoms could identify children at risk for imaging abnormalities that require further management.

Shortened Taper Duration after Implementation of a Standardized Protocol for Iatrogenic Benzodiazepine and Opioid Withdrawal in Pediatric Patients: Results of a Cohort Study.

INTRODUCTION: Methadone and lorazepam prescribing discrepancies for the use of iatrogenic withdrawal were observed among providers. A standardized pharmacist-managed methadone and lorazepam taper protocol was implemented at a pediatric tertiary care facility with the aim to reduce the length of taper for patients with iatrogenic withdrawal. METHODS: A multidisciplinary team of nurses, pharmacists, and physicians reviewed the current literature, then developed and implemented a standardized withdrawal taper protocol. Outcomes were compared with a retrospective control group using past prescribing practices. The primary endpoint was the length of methadone and/or lorazepam taper. Secondary endpoints included evaluation for significant differences between the control and standardized protocol groups regarding additional breakthrough withdrawal medications, pediatric intensive care unit (PICU) and hospital length of stay. We also evaluated provider satisfaction with the protocol. RESULTS: The standardized protocol group included 25 patients who received methadone and/or lorazepam taper. A retrospective control group contained 24 patients. Median methadone taper length before protocol implementation was 9.5 days with an interquartile range (IQR) of 5.5-14.5 days; after protocol implementation, it was 6.0 (IQR, 3.0-9.0) days (P = 0.0145). Median lorazepam taper length before protocol implementation was 13.0 (IQR, 8.0-18.0) days; after protocol implementation, it was 6.0 (4.0-7.0) days (P = 0.0006). A statistical difference between PICU length of stay, hospital length of stay, or the number of additional medications for breakthrough withdrawal was not found. CONCLUSIONS: The use of a standardized withdrawal protocol resulted in shorter taper duration for both the methadone and lorazepam groups. There was no difference in PICU or hospital length of stay.

Work-Life Balance in Women Physicians in South Dakota: Results of a State-Wide Assessment Survey.

INTRODUCTION/BACKGROUND: There is currently a high prevalence of burnout among women physicians. This is associated with factors related to job satisfaction and work-life balance. Female physicians are more likely to experience burnout and related negative consequences. Preventing burnout among physicians improves wellness in both doctors and patients. The goal of this study is to determine burnout among physicians in South Dakota and identify possible burnout prevention strategies to improve work-life balance. METHODS: South Dakota State Medical Association (SDSMA) physician members were emailed a survey with anonymous responses in November 2017 and January 2018. Survey questions were based on a 5-point Likert scale with two open-ended questions which were evaluated by qualitative measures. RESULTS: A total of 1,989 surveys were administered with 433 responses (21.8 percent). Of the 433 survey responses, 133 individuals provided additional comments regarding work-life balance. A slender majority of male and female physicians are satisfied with their work-life balance (54.7 and 55.4 percent, respectively). Both men and women physicians would choose the same specialty again (78.2 and 74.8 percent, respectively) as well as choose to be a physician again (79.4 and 78.7 percent respectively). Overall, women suggested more time for administrative tasks, more flexible hours, offering daycare at the hospital. CONCLUSIONS: Possible workplace interventions to prevent physician burnout include hiring scribes, allocating time for administrative work, and allowing less work hours. Personal strategies aiding in work-life balance include utilizing daycares, having supportive families, and hiring individuals to assist in daily home tasks.

Neutrophil Phenotype Correlates With Postoperative Inflammatory Outcomes in Infants Undergoing Cardiopulmonary Bypass.

OBJECTIVES: Infants with congenital heart disease frequently require cardiopulmonary bypass, which causes systemic inflammation. The goal of this study was to determine if neutrophil phenotype and activation status predicts the development of inflammatory complications following cardiopulmonary bypass. DESIGN: Prospective cohort study. SETTING: Tertiary care PICU with postoperative cardiac care. PATIENTS: Thirty-seven patients 5 days to 10 months old with congenital heart disease requiring cardiopulmonary bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Laboratory and clinical data collected included length of mechanical ventilation, acute kidney injury, and fluid overload. Neutrophils were isolated from whole blood at three time points surrounding cardiopulmonary bypass. Functional analyses included measurement of cell surface protein expression and nicotinamide adenine dinucleotide phosphate oxidase activity. Of all patients studied, 40.5% displayed priming of nicotinamide adenine dinucleotide phosphate oxidase activity in response to N-formyl-Met-Leu-Phe stimulation 24 hours post cardiopulmonary bypass as compared to pre bypass. Neonates who received steroids prior to bypass demonstrated enhanced priming of nicotinamide adenine dinucleotide phosphate oxidase activity at 48 hours. Patients who displayed priming post cardiopulmonary bypass were 8.8 times more likely to develop severe acute kidney injury as compared to nonprimers. Up-regulation of neutrophil surface CD11b levels pre- to postbypass occurred in 51.4% of patients, but this measure of neutrophil priming was not associated with acute kidney injury. Subsequent analyses of the basal neutrophil phenotype revealed that those with higher basal CD11b expression were significantly less likely to develop acute kidney injury. CONCLUSIONS: Neutrophil priming occurs in a subset of infants undergoing cardiopulmonary bypass. Acute kidney injury was more frequent in those patients who displayed priming of nicotinamide adenine dinucleotide phosphate oxidase activity after cardiopulmonary bypass. This pilot study suggests that neutrophil phenotypic signature could be used to predict inflammatory organ dysfunction.

Endotoxin priming of neutrophils requires endocytosis and NADPH oxidase-dependent endosomal reactive oxygen species.

NADPH oxidase 2 (Nox2)-generated reactive oxygen species (ROS) are critical for neutrophil (polymorphonuclear leukocyte (PMN)) microbicidal function. Nox2 also plays a role in intracellular signaling, but the site of oxidase assembly is unknown. It has been proposed to occur on secondary granules. We previously demonstrated that intracellular NADPH oxidase-derived ROS production is required for endotoxin priming. We hypothesized that endotoxin drives Nox2 assembly on endosomes. Endotoxin induced ROS generation within an endosomal compartment as quantified by flow cytometry (dihydrorhodamine 123 and Oxyburst Green). Inhibition of endocytosis by the dynamin-II inhibitor Dynasore blocked endocytosis of dextran, intracellular generation of ROS, and priming of PMN by endotoxin. Confocal microscopy demonstrated a ROS-containing endosomal compartment that co-labeled with gp91(phox), p40(phox), p67(phox), and Rab5, but not with the secondary granule marker CD66b. To further characterize this compartment, PMNs were fractionated by nitrogen cavitation and differential centrifugation, followed by free flow electrophoresis. Specific subfractions made superoxide in the presence of NADPH by cell-free assay (cytochrome c). Subfraction content of membrane and cytosolic subunits of Nox2 correlated with ROS production. Following priming, there was a shift in the light membrane subfractions where ROS production was highest. CD66b was not mobilized from the secondary granule compartment. These data demonstrate a novel, nonphagosomal intracellular site for Nox2 assembly. This compartment is endocytic in origin and is required for PMN priming by endotoxin.