A Quality Improvement Project to Increase Nurse Attendance on Pediatric Family Centered Rounds.

UNLABELLED: Family centered rounds (FCR) occur at the bedside and include the patient and their family when creating a daily medical care plan. Despite recommendations that family centered rounds (FCR) with nursing staff be standard practice, nurses were frequently absent from FCR at our institution. OBJECTIVE: To increase nurse attendance on hospitalist FCR to 80% in three months. Secondary outcomes were to investigate the relationship between nurse-to-patient ratio and nurse attendance, and to assess for change in perception toward FCR. METHODS: This resident driven interrupted time series study included a focus group to identify barriers to nurse attendance on FCR, four plan-do-study-act cycles, and surveys to assess for changes in perceptions toward FCR. Control charts, SHEWHART rules, linear regression and chi squared analysis were used for data analysis. RESULTS: Nurse attendance on FCR improved from 30% to 59%. There was no correlation between nurse-to-patient ratio and nurse attendance on FCR. Surveys indicated increase in the perception that it is helpful to have a nurse present at FCR. CONCLUSIONS: A resident driven quality improvement project can increase nurse presence on FCR.

Hyperhemolysis in sickle cell disease.

An 18-year-old female with sickle cell disease presented with thigh pain, dark urine, and hematuria within 72 hours of receiving a blood transfusion. Her clinical picture was consistent with hemolysis. Subsequent laboratory workup, however, demonstrated reticulocytopenia without evidence of an antibody-mediated transfusion reaction. As her hemoglobin continued to decrease, she was treated with IVIG and steroids for presumed hyperhemolysis. Clinicians should have a high index of suspicion for hyperhemolysis in sickle cell patients with evidence of hemolysis after a recent transfusion. Differentiating hyperhemolysis from other hemolytic syndromes is critical; transfusions in a hyperhemolytic episode can accelerate hemolysis causing life-threatening anemia.

Probiotics for managing patients after bowel preparation for colonoscopy: an interventional, double-arm, open, randomized, multi-center, and national study (COLONSTUDY).

BACKGROUND: Bowel preparation (BP) for colonoscopy induces significant changes in gut microbiota, causing dysbiosis that, in turn, elicits intestinal symptoms. Consequently, probiotics may counterbalance the disturbed microbiota after BP. So, probiotics may restore microbiota homeostasis. METHODS: The current study evaluated the efficacy and safety of Abincol®, an oral nutraceutical containing a probiotic mixture with Lactobacillus plantarum LP01 (1 billion living cells), Lactobacillus lactis subspecies cremoris LLC02 (800 millions living cells), and Lactobacillus delbrueckii LDD01 (200 millions living cells), Patients were randomized in two groups (2:1). Group A took one stick/daily for four weeks after colonoscopy. Group B was considered as control. Patients were evaluated at baseline (T0) and after one (T1), two (T2), and four (T3) weeks. The severity of symptoms was measured by patients using a Visual Analog Scale. RESULTS: Abincol® significantly diminished the presence and the severity of intestinal symptoms at T2 and even more at T3. All patients well tolerated the probiotic mixture. CONCLUSIONS: The present study suggests that Abincol® may be considered an effective and safe therapeutic option in managing patients undergoing BP. The course should last one month.

Trends in and Documentation of Refusal of Common Routine Newborn Interventions: 2013-2019.

BACKGROUND: Refusals of intramuscular (IM) vitamin K, ocular prophylaxis, and hepatitis B vaccine (HBV) during the birth hospitalization continue to occur. Refusal of IM vitamin K increases the risk of life-threatening vitamin K deficiency bleeding. Trends in refusal rates and how well clinicians document IM vitamin K refusal is unknown. METHODS: We reviewed charts of livebirths admitted to 5 well newborn units from 2013 to 2019. We report trends in rates of refusal and documentation of no IM vitamin K by clinicians during the birth hospitalization and within the first 6 months of life at emergency department (ED) visits. RESULTS: Of 67 750 live births, 283 (0.4%) did not receive IM vitamin K, and 1645 (2.4%) did not receive ocular prophylaxis. Rates of IM vitamin K refusal increased slightly over time (P < .05). For HBV, 7551 (11.1%) did not receive the birth dose, but refusal rates decreased from 16.1% to 8.7% (P < .0001). Of 283 newborns who did not receive IM vitamin K, refusal was documented in 49.8% of discharge summaries, 17 (6%) had an invasive procedure without documentation of IM vitamin K administration, and 30 (10.6%) infants <6 months old had ED visits. A total of 4 infants were evaluated for potential bleeding, and there was no documentation about IM vitamin K prophylaxis. CONCLUSION: Refusal rates of IM vitamin K and ocular prophylaxis remained low, and uptake of HBV increased over time. Documentation of IM vitamin K refusal by clinicians during the birth hospitalization, before invasive procedures, and in ED visits can be improved.

Well-Newborn Unit Director Experiences During the COVID-19 Pandemic: A BORN Study.

BACKGROUND: As coronavirus disease 2019 (COVID-19) spread across the country, well-newborn unit medical directors developed newborn care plans as guidelines and evidence evolved. We chose to examine approaches to newborn care during these early phases of the COVID-19 pandemic. METHODS: An electronic survey was administered to well-newborn unit directors in a national network of US well-newborn units in May 2020. Respondents were asked about their approaches to testing, infection prevention, routine newborn care, discharge planning, breastfeeding, rounding, and teaching. RESULTS: Of 107 sites, 65 (61%) respondents completed the survey. Respondents estimated a 1% positivity rate of 1198 newborns tested for COVID-19. Most sites (86%) performed universal maternal COVID-19 testing, and most (82%) tested newborns of COVID-19-positive mothers at 24 hours of life (75%). Infection prevention and visitation policies varied. Of respondents, in COVID-19-positive mothers, 28% permitted no visitors, 54% recommended rooming-in with the newborn, 55% encouraged breastfeeding at the breast, 38% deferred routine circumcisions of the newborn, 74% initiated immediate bathing of the newborn, 68% continued standard newborn screening, and 55% modified newborn follow-up plans. Medical directors reported adjustments to rounding and teaching workflow. Content analysis of free-text responses revealed themes related to challenges with changing recommendations, discomfort with mother-infant separation recommendations, innovations, and stress management. CONCLUSIONS: Well-newborn units quickly adopted universal maternal testing and testing of exposed newborns. Despite guidelines, we identified variation in the care of newborns of COVID-19-positive mothers. Further investigation of these differences and newborn outcomes is warranted to develop best practices.

Vision-related quality of life and locus of control in type 1 diabetes: a multicenter observational study.

AIMS: Diabetic retinopathy remains asymptomatic until its late stages but remains a leading cause of vision impairment and blindness. We studied quality of life and the ability to deal with the discomfort deriving from the presence of a chronic disease in patients with type 1 diabetes and different stages of retinopathy. METHODS: Multicenter collaborative observational study involving nine centers screening for retinopathy in different areas of Italy. The National Eye Institute 25-item visual functioning questionnaire and the locus of control tool were administered to 449 people with type 1 diabetes between February 2016 and March 2018. Socio-demographic and clinical data were collected. RESULTS: On multivariable analysis, severe retinopathy is associated with worse scores for general vision, ocular pain, near vision activities, distance vision activities, driving, color vision, peripheral vision and lower values of internal control, independently of visual acuity. Women had a perception of worse general health, distance vision activities and driving, and lower internal control and trust in others. Worse scores for visual-specific social functioning, visual-specific mental health, visual-specific role difficulties, visual-specific dependency and peripheral vision were associated with higher HbA1c levels. Fatalism increased with rising HbA1c levels. CONCLUSIONS: These results confirm that a gap exists between patients' knowledge and expectations on retinopathy and providers' expertise and assumptions. To bridge this gap, patient-centered education and engaging approaches may be more effective than simple information given during consultations.

Newborn Care Curriculum: The Late Preterm Infant in the Level II Neonatal Intensive Care Unit.

Introduction: Late preterm births represent the largest category of preterm deliveries. Although these infants are frequently managed in normal newborn nurseries, they have an increased risk of readmissions and mortality. Thus, we designed this PowerPoint-based learning module to provide learners with a computer-based educational resource on late preterm infants in the level II neonatal intensive care unit. Methods: This module can be completed using the included pretest and posttest to assess for change in knowledge. The module should take approximately 20 to 30 minutes to complete. Results: Between May and June of 2016, members of the pediatric hospitalist division at Children's National Health System in Washington, DC participated in a study of the module as a self-directed learning tool and completed the pretest, posttest, and postmodule evaluation forms. There was an overall increase in knowledge, with an increase in posttest score from 64% to 94%. Furthermore, this module was well-received by learners, as 55% of learners agreed or strongly agreed that the material presented in the module would change their clinical practice, and 100% agreed or strongly agreed that the module increased their comfort with teaching on this topic. Discussion: Initial implementation of the module indicates it could be a valuable tool to address a perceived educational need in the area of late preterm infant care in the level II neonatal intensive care unit.

Removing Race From Hyperbilirubinemia Guidelines Is Not Enough.

This Viewpoint discusses the complexities of race-conscious medicine and the importance of more explicit and attentive guidance in treatment recommendations.

Comparison of Clinical Risk Factors Among Pediatric Patients With Single Admission, Multiple Admissions (Without Any 7-Day Readmissions), and 7-Day Readmission.

BACKGROUND AND OBJECTIVE: Readmissions have received increasing attention. The goal of this study was to identify demographic and clinical factors associated with hospital utilization and 7-day readmissions. METHODS: This retrospective case-control study of inpatient and observation encounters was conducted at a freestanding children's hospital. Over a 1-year period, patients were categorized into 3 groups: patients with a single admission, patients with multiple admissions without any 7-day readmissions, and patients with at least one 7-day readmission. Factors associated with risk of future hospital utilization were determined, and post hoc testing was performed to compare groups. RESULTS: Patients with a single admission had statistically significant lower numbers of medications at admission and discharge, lower rates of home health care at admission and discharge, and fewer diagnosis codes during index admission than patients with multiple admissions. There were no statistically significant differences among patients with multiple admissions between those with and without 7-day readmissions. CONCLUSIONS: This study found that patients with multiple admissions were similar regardless of whether they had any 7-day readmissions. Because patients with multiple admissions seemed to represent a single high-risk group, it is possible that many readmissions represent a consequence of medical complexity rather than a failure of care. Further studies are necessary to determine if providing targeted interventions to high-risk patients will lower their future hospital utilization.

Impact of Obesity on Clinical Outcomes in Urban Children Hospitalized for Status Asthmaticus.

BACKGROUND AND OBJECTIVE: The prevalence of both childhood asthma and obesity remain at historically high levels and disproportionately affect urban children. Asthma is a common and costly cause for pediatric hospitalization. Our objective was to determine the effect of obesity on outcomes among urban children hospitalized with status asthmaticus. METHODS: A retrospective cohort study was performed by using billing system data and chart review to evaluate urban children admitted for asthma. Demographics, asthma severity, reported comorbidities, and outcomes were assessed. Obesity was defined by BMI percentile (lean<85%, overweight 85%-95%, obese≥95%). Outcomes were length of stay, hospitalization charges, ICU stay, repeat admissions, and subsequent emergency department (ED) visits. Bivariate analysis assessed for differences between overweight/obese and lean children. Multivariable regression assessed the relationship between overweight status and primary outcomes while controlling for other variables. Post hoc age-stratified analysis was also performed. RESULTS: The study included 333 subjects; 38% were overweight/obese. Overweight/obese children admitted with asthma were more likely than lean children to have subsequent ED visits (odds ratio 1.6, 95% confidence interval 1.0-2.6). When stratified by age, overweight/obese preschool-age children (<5 years) were >2 times as likely to have repeat ED visits than lean preschool-age children (odds ratio 2.3, 95% confidence interval 1.0-5.6). There were no differences in the other outcomes between overweight/obese and lean individuals within the entire cohort or within other age groups.