Targeted Clinical Interventions for Reducing Pediatric Readmissions.

BACKGROUND: In this interventional study, we addressed the selection and application of clinical interventions on pediatric patients identified as at risk by a predictive model for readmissions. METHODS: A predictive model for readmissions was implemented, and a team of providers expanded corresponding clinical interventions for at-risk patients at a freestanding children's hospital. Interventions encompassed social determinants of health, outpatient care, medication reconciliation, inpatient and discharge planning, and postdischarge calls and/or follow-up. Statistical process control charts were used to compare readmission rates for the 3-year period preceding adoption of the model and clinical interventions with those for the 2-year period after adoption of the model and clinical interventions. Potential financial savings were estimated by using national estimates of the cost of pediatric inpatient readmissions. RESULTS: The 30-day all-cause readmission rates during the periods before and after predictive modeling (and corresponding 95% confidence intervals [CI]) were 12.5% (95% CI: 12.2%-12.8%) and 11.1% (95% CI: 10.8%-11.5%), respectively. More modest but similar improvements were observed for 7-day readmissions. Statistical process control charts indicated nonrandom reductions in readmissions after predictive model adoption. The national estimate of the cost of pediatric readmissions indicates an associated health care savings due to reduced 30-day readmission during the 2-year predictive modeling period at $2 673 264 (95% CI: $2 612 431-$2 735 364). CONCLUSIONS: A combination of predictive modeling and targeted clinical interventions to improve the management of pediatric patients at high risk for readmission was successful in reducing the rate of readmission and reducing overall health care costs. The continued prioritization of patients with potentially modifiable outcomes is key to improving patient outcomes.

Mental Health and Self-Care Practices Among Dental Hygienists.

Purpose: Occupational stress and burn-out among dental hygienists may produce a decrease in overall mental health and well-being. The purpose of this study was to determine prevalence of mental health concerns as well as perceived stressors and self-care strategies among dental hygienists in Oregon.Methods: Dental hygienists belonging to the Oregon Dental Hygienists' Association were invited to participate in an electronic survey. The validated and pilot tested-survey consisted of 28 items that addressed experiences with stress, mental health issues and coping mechanisms. Descriptive and inferential statistics were used to analyze the data.Results: Of the email invitations that were successfully delivered (n=251), 83 dental hygienists volunteered to participate (n=83), for a 33% response rate. Difficulty maintaining work-life balance (35%, n=28), dysfunctional work teams (34%, n=28), and not enough time in the work schedule (65%, n=54) were the most common stressors. Respondents who worked ≥20 hours per week were more likely to attribute their daily stress primarily or entirely to work (p=0.009). Self-care methods included exercise, quiet time, spending time with loved ones, and self-care activities. Only 21% of respondents (n=17) reported that they received information or training on stress management and or burn-out in as part of their dental hygiene education.Conclusion: Symptoms linked to depression and anxiety are common among dental hygienists in Oregon. Stress management education and training should be incorporated in dental hygiene educational programs to prepare graduates to effectively manage the stressors that may lead to burn-out. Additional research should be conducted on a national level to gain a more representative sample.

Adherence to Daily Weights and Total Fluid Orders in the Pediatric Intensive Care Unit.

BACKGROUND: Fluid is central to the resuscitation of critically ill children. However, many pay limited attention to continued fluid accumulation. Fluid overload (FO) is associated with significant morbidity and mortality. The Volume Status Awareness Program (VSAP) is a multi-phase quality improvement initiative aimed at reducing iatrogenic FO. For baseline data, the authors examined a retrospective cohort of patients admitted to the pediatric intensive care unit. METHODS: Cohort included diuretic-naive patients admitted to the pediatric intensive care unit at a tertiary care children's hospital in 2014. Furosemide-exposure was used to indicate provider-perceived FO. Variables included daily weight and total fluid (TF) orders, and their timing, frequency, and adherence. Implementation of VSAP phase 1 (bundle of interventions to promote consistent use of patient weights) occurred in June 2017. RESULTS: Forty-nine patients met criteria. Five (10%) had daily weight orders, and 41 (84%) had TF orders-although 7 of these orders followed furosemide administration. Adherence to TF orders was good with 32 (78%) patients exceeding TF limits by < 10%. Thirty (63%) had > 5% FO by day 1, and 22 (51%) had > 10% cumulative FO by day 3. Following phase 1 of the VSAP, the frequency of daily weight orders increased from 6% to 88%. CONCLUSIONS: In our institution, use of fluid monitoring tools is both inconsistent and infrequent. Early data from the VSAP project suggests simple interventions can modify ordering and monitoring practice, but future improvement cycles are necessary to determine if these changes are successful in reducing iatrogenic FO.

Hyperchloremia is independently associated with mortality in critically ill children who ultimately require continuous renal replacement therapy.

BACKGROUND: The optimal fluid management in critically ill children is currently under investigation with several studies suggesting that hyperchloremia, chloride load, and the use of chloride-rich fluids contribute to worse outcomes. METHODS: This is a single-center retrospective cohort study of Pediatric Intensive Care Unit patients from 2008 to 2016 requiring continuous renal replacement therapy (CRRT). Patients were excluded if they had end-stage renal disease, a disorder of chloride transport, or concurrent provision of extracorporeal membrane oxygenation therapy. RESULTS: Patients (n = 66) were dichotomized into two groups (peak chloride (Cl) ≥ 110 mmol/L vs. peak Cl < 110 mmol/L prior to CRRT initiation). Hyperchloremia was present in 39 (59%) children. Baseline characteristics were similar between groups. Fluid overload at CRRT initiation was more common in patients with hyperchloremia (11.5% IQR 3.8-22.4) compared to those without (5.5% IQR 0.9-13.9) (p = 0.04). Mortality was significantly higher in patients with hyperchloremia (n = 26, 67%) compared to those without (n = 8, 29%) (p = 0.006). Patients with hyperchloremia had 10.9 times greater odds of death compared to those without hyperchloremia, after adjusting for percent fluid overload, PRISM III score, time to initiation of CRRT, height, and weight (95% CI 2.4 to 49.5, p = 0.002). CONCLUSIONS: Hyperchloremia is common among critically ill children prior to CRRT initiation. In this population, hyperchloremia is independently associated with mortality. Further studies are needed to determine the impact of hyperchloremia on all critically ill children and the impact of chloride load on outcomes.

Choosing Wisely Campaign: Report Card and Achievable Benchmarks of Care for Children's Hospitals.

OBJECTIVES: In 2013, the Society of Hospital Medicine (SHM) released 5 pediatric recommendations for the Choosing Wisely Campaign (CWC). Our goals were to develop a report card on the basis of those recommendations, calculate achievable benchmarks of care (ABCs), and analyze performance among hospitals participating in the Pediatric Health Information System. METHODS: Children hospitalized between January 2013 and September 2015 from 32 Pediatric Health Information System hospitals were studied. The quality metrics in the report card included the use of chest radiograph (CXR) in asthma and bronchiolitis, bronchodilators in bronchiolitis, systemic corticosteroids in lower respiratory tract infections (LRTI), and acid suppression therapy in gastroesophageal reflux (GER). ABCs were calculated for each metric. RESULTS: Calculated ABCs were 22.3% of patients with asthma and 19.8% of patients with bronchiolitis having a CXR, 17.9% of patients with bronchiolitis receiving bronchodilators, 5.5% of patients with LRTIs treated with systemic corticosteroids, and 32.2% of patients with GER treated with acid suppressors. We found variation among hospitals in the use of CXR in asthma (median: 34.7%, interquartile range [IQR]: 28.5%-45.9%), CXR in bronchiolitis (median: 34.4%, IQR: 27.9%-49%), bronchodilators in bronchiolitis (median: 55.4%, IQR: 32.3%-64.9%), and acid suppressors in GER (median: 59.4%, IQR: 49.9%-71.2%). Less variation was noted in the use of systemic corticosteroids in LRTIs (median: 13.5%, IQR: 11.1%-17.9%). CONCLUSIONS: A novel report card was developed on the basis of the SHM-CWC pediatric recommendations, including ABCs. We found variance in practices among institutions and gaps between hospital performances and ABCs. These findings represent a roadmap for improvement.

Implementation of Nutrition Support Guidelines May Affect Energy and Protein Intake in the Pediatric Intensive Care Unit.

BACKGROUND: Critically ill children are at risk of developing malnutrition, and undernutrition is a risk factor for morbidity and mortality. OBJECTIVE: The study evaluated changes in the energy and protein intake before and after implementation of nutrition support (NS) guidelines for a pediatric critical care unit (PICU). DESIGN: This retrospective study documented energy and protein intake for the first 8 days of PICU stay. Basal metabolic rate and protein needs were estimated by Schofield and American Society for Parenteral and Enteral Nutrition Guidelines, respectively. PARTICIPANTS/SETTING: Three hundred thirty-five children from August to December 2012 (pre-implementation) and 185 from October to December 2013 (post-implementation). INTERVENTION: Implementation of NS Guidelines. MAIN OUTCOME MEASURES: Changes in actual energy and protein intake in the post- compared with the pre-Implementation period. STATISTICAL ANALYSIS PERFORMED: Unpaired t tests, Pearson's χ(2) (unadjusted analysis) were used. Logistic regressions were used to estimate odds ratios and 95% confidence intervals for protein and energy intake, adjusted for age, sex, and Pediatric Risk of Mortality score. RESULTS: After the implementation of guidelines, significant improvements were seen during days 5 through 8 in energy intake among children 2 years of age and older, and in protein intake in both age groups (P<0.05). For the 8-day period, statistically or clinically significant improvements occurred in the cumulative protein deficit/kg/day, as follows: younger than 2-year-olds, -1.5±0.7 g/kg/day vs -1.3±0.8 g/kg/day, P=0.02; 2-year-olds or older, -1.0±0.6 g/kg/day vs -0.7±0.8 g/kg/day, P=0.01; and for the energy deficit/kg/d in 2-year-olds and older, -17.2±13.6 kcal/kg/day vs -13.3±18.1 kcal/kg/day, unpaired t test, P=0.07, in the pre- vs post-implementation period, respectively. CONCLUSIONS: The implementation of NS guidelines was associated with improvements in total energy in 2-year-olds and older and protein in younger than 2 and 2 years and older children by days 5 through 8, and protein deficits were significantly lower in the post- vs the pre-implementation period. The implementation of NS guidelines may have had a positive effect on improving NS in critically ill children.