Temporal Relationship of Onset of Necrotizing Enterocolitis and Introduction of Enteric Feedings and Powdered Milk Fortifier.

OBJECTIVE: This article evaluates temporal relationships between onset of necrotizing enterocolitis (NEC) in preterm infants and introduction of enteral feedings or powdered human milk fortifier (HMF). STUDY DESIGN: This is a Poisson regression analysis of NEC cases at a single children's hospital between 1999 and 2009, using the self-controlled case series method to estimate adjusted daily event rate ratios (DERR) during postexposure intervals. RESULTS: Of 139 patients with a clinical diagnosis of NEC, 26 had early disease onset prior to initiation of feeding and were considered to be cases of spontaneous intestinal perforation (SIP). For the remaining 113 infants, the DERR for NEC onset were significantly greater on days for which infants were <14 days of age (DERR, 2.15; 95% confidence interval [CI], 1.22-3.79) or ≥31 weeks postmenstrual age (2.94; 95% CI, 1.51-5.83) or which fell within 14 days after initiation of enteric feeding (8.29; 95% CI, 4.73-14.53) or 4 days after introduction of HMF (12.32; 95% CI, 7.13-21.29). CONCLUSION: There are strong temporal associations between onset of NEC and initiation of enteral feeding or powdered HMF in preterm infants.

Impacting Satisfaction, Learning, and Efficiency Through Structured Interdisciplinary Rounding in a Pediatric Intensive Care Unit: A Quality Improvement Project.

BACKGROUND: Daily rounds in many pediatric intensive care units (PICUs) vary in quality, duration, and participation. We hypothesized that implementing structured interdisciplinary bedside rounds (SIBR®) would improve our rounding process. METHODS: This was a quality improvement initiative in a 25-bed multidisciplinary PICU in a tertiary children's hospital. Baseline data included rounding duration; participation of nurses, respiratory care practitioners (RCP), parents; and physician order read-back practices. Interventions were implementing pre-rounding huddles, changing the start of the rounding week, and instituting a SIBR model. All staff, consecutive patients and parents participated over 18 months. We used Mann-Whitney, z-test, and t-tests for statistical analysis with a significance level of 0.05. We tracked data with a statistical process control chart. RESULTS: Rounds participation increased for nurses (88% to 100%), RCPs (13% to 61%), and families (24% to 49%) (all p <0.001). Physician order read-back increased (41% to 79%) (p<0.001). The median length of stay (LOS) decreased from 2.1 to 1.9 days (p=0.004) with no changes in mortality or readmissions. The proportion of top responses from family surveys increased from 0.69 to 0.76 (p<0.001). PICU rounding duration (minutes/patient) decreased from 17.1 to 11.3. Most resident physicians felt SIBR positively impacted their education (70%), was more effective than rounds without structure (97%), and that family presence positively impacted learning (70%). CONCLUSIONS: Implementing a SIBR process in our PICU resulted in greater family and staff satisfaction, improved workflow and decreased rounding time by 34% without compromising education. LOS decreased significantly with no increases in mortality or readmissions.

Better health, less spending: Redesigning the transition from pediatric to adult healthcare for youth with chronic illness.

Adolescents and young adults (AYA) with serious chronic illnesses face costly and dangerous gaps in care as they transition from pediatric to adult health systems. New, financially sustainable approaches to transition are needed to close these gaps. We designed a new transition model for adolescents and young adults with a variety of serious chronic conditions. Our explicit goal was to build a model that would improve the value of care for youth 15-25 years of age undergoing this transition. The design process incorporated a review, analysis, and synthesis of relevant clinical and health services research; stakeholder interviews; and observations of high-performing healthcare systems. We identified three major categories of solutions for a safer and lower cost transition to adult care: (1) building and supporting self-management during the critical transition; (2) engaging receiving care; and (3) providing checklist-driven guide services during the transition. We propose that implementation of a program with these interventions would have a positive impact on all three domains of the triple aim - improving health, improving the experience of care, and reducing per capita healthcare cost. The transition model provides a general framework as well as suggestions for specific interventions. Pilot tests to assess the model's ease of implementation, clinical effects, and financial impact are currently underway.