Attitudes and Intentions toward Use of HIV Pre-Exposure Prophylaxis (PrEP) among Adults Receiving Treatment for Opioid Use.

Background: Although pre-exposure prophylaxis (PrEP) prevents HIV, little is known about PrEP awareness and factors associated with intention to take PrEP among people with opioid use disorder (OUD). Methods: HIV-negative adults recruited from an outpatient treatment program in Cincinnati, Ohio completed self-administered surveys. Items derived from literature and health behavioral theory included demographics, sexual and drug use behaviors, HIV prevention practices, PrEP knowledge, and attitudes toward PrEP. Primary outcomes were 1) intention to ask a clinician about PrEP and 2) intention to accept PrEP if recommended by a clinician. Outcomes were dichotomized into higher vs. lower intention for analyses in logistic regression models. Results: Among 198 participants, 60.3% reported past injection drug use. Among 58 participants (29.3%) meeting criteria for PrEP, 24% were aware of PrEP, 15.5% had discussed it with a clinician, and 5% had taken it. Factors associated with intention to ask a clinician about PrEP included being somewhat confident about consistent condom use (p < 0.01), motivation to comply with normative beliefs (p < 0.01), and reporting that PrEP fits very well (p < 0.01) and is easy to fit (p < 0.01) into current prevention practices. Factors associated with intention to accept PrEP if recommended by a clinician included motivation to comply with normative beliefs (p < 0.01) and PrEP being easy to fit into current prevention practices (p < 0.01). Conclusion: Among participants meeting indications for PrEP, only 24% were aware of it and few had taken it. Interventions that normalize PrEP and target incorporating PrEP into current prevention practices may improve uptake among individuals with OUD.

Contemporary outcomes for functional single ventricle with total anomalous pulmonary venous connection.

OBJECTIVE: In 2004, we reported improved early survival for patients with functional single ventricle anatomy and total anomalous pulmonary venous connection. This study sought to discover if outcomes have been ameliorated in the contemporary era. METHODS: This was a single-center review of patients with single ventricle anatomy and total anomalous pulmonary venous connection who were admitted from 1984 to 2021. The cohort was divided into similarly sized groups by date of admission: Era 1: 1984 to 1992, Era 2: 1993 to 2007, and Era 3: 2008 to 2021. Survival was compared, and Cox proportional hazards models were used to evaluate the likelihood of mortality. RESULTS: We included 190 patients with single ventricle anatomy and total anomalous pulmonary venous connection. Unbalanced atrioventricular canal defect (70%) was the most common primary diagnosis. The most common type of total anomalous pulmonary venous connection was supracardiac (49%). Approximately one-third (32%) of patients had pulmonary venous obstruction. There were no significant differences in patient characteristics across eras. Early survival after initial palliative operation improved between Eras 1 and 2, and then remained stable in Era 3. Overall survival improved from Era 1 to Eras 2 and 3 (P < .001), but not between Era 2 and 3. Survival to 10 years by Eras 1 to 3 was 15%, 51%, and 54%, respectively. The anatomic features associated with worse survival were hypoplastic left heart syndrome diagnosis (hazard ratio, 1.60; 1.04-2.57) and pulmonary venous obstruction (hazard ratio, 1.80; 1.24-2.69). CONCLUSIONS: Overall survival for patients with single ventricle anatomy and total anomalous pulmonary venous connection has plateaued since the early 2000s. Even in the most recent era, survival to age 10 years remains less than 60%. Risk factors for mortality include the diagnosis of hypoplastic left heart syndrome and pulmonary venous obstruction. Further studies should focus on identification of the pathophysiological factors underlying the increased mortality.

Inpatient Physical Therapy After Orthopedic Lower Extremity Surgery in Children With Cerebral Palsy.

PURPOSE: To characterize and examine the variability in receipt of inpatient (IP) physical therapy after lower extremity (LE) orthopedic surgery for individuals with cerebral palsy (CP) across hospital-level (region, bed size) and individual characteristics (gender, age, race/ethnicity, insurance type, technology dependency, and surgical burden). METHODS: We retrospectively analyzed physical therapy billing data of children with CP who had LE orthopedic surgery from October 1, 2015, through September 30, 2017, from the Pediatric Health Information Services (PHIS) database. RESULTS: Seventy-five percent of individuals received IP physical therapy during the hospital stay. Individuals from the South and West and those who were technology dependent were less likely to receive IP therapy. Those at large hospitals, aged 11 to 14 years, and with a high surgical burden were more likely to receive therapy. CONCLUSIONS: Results provide a starting point for future research on the discrepancies of acute physical therapy services in children diagnosed with CP. (Supplemental digital content video abstract available at: http://links.lww.com/PPT/A420).

Beta-Lactam Allergy Association with Surgical Site Infections in Pediatric Procedures: A Matched Cohort Study.

BACKGROUND: Little is known about surgical site infection (SSI) risk among pediatric patients with reported beta-lactam allergy (BLA). METHODS: We performed a retrospective cohort study at a quaternary children's hospital and compared procedures in patients ages 1-19 years old with and without BLA that required antimicrobial prophylaxis (AMP) during 2010-2017. Procedures were matched 1:1 by patient age, complex chronic conditions, year of surgery, and National Surgical Quality Improvement Program current procedural terminology category. The primary outcome was SSI as defined by National Healthcare Safety Network. The secondary outcome was AMP protocol compliance as per American Society of Health-System Pharmacists. RESULTS: Of the 11 878 procedures identified, 1021 (9%) had a reported BLA. There were 35 (1.8%) SSIs in the matched cohort of 1944 procedures with no significant difference in SSI rates in BLA procedures (1.8%) compared to no-BLA (1.9%) procedures. Tier 3 AMP was chosen more frequently among BLA procedures (P < .01). Unmatched analysis of all procedures showed that 23.7% of BLA procedures received beta-lactam-AMP (vs. 93.7% of procedures without BLA). There were no major differences in SSI on sensitivity analysis of BLA procedures that did not receive beta-lactam AMP (1.4%) compared to no-BLA procedures with beta-lactam AMP (1.6%). CONCLUSIONS: Our retrospective matched analysis of 1944 pediatric procedures found no increase in SSIs in procedures with reported BLA, which differs from studies in adults. We observed that the choice of beta-lactam-AMP was common, even in BLA procedures. More data are needed to delineate an association between non-beta-lactam AMP and SSI in children.

Spica Casting of Pediatric Femur Fractures: The Pain Management Experience at One Institution.

Objectives Currently, very little literature exists regarding the "fifth vital sign" in pediatric orthopedics, pain. Multiple studies have highlighted the utility of non-narcotic pain medications in treating acute pain. The objective of this study is to determine the type and amount of pain medication(s) administered and subsequently prescribed to pediatric patients ages six months to five years old with femur fractures treated with spica casting in the ER (emergency room) and OR (operative room). We also determined the incidence of spica cast change necessary for the two groups as a secondary outcome. Methods A retrospective review was completed at a single level 1 pediatric trauma center, evaluating 82 patients who met the inclusion criteria between six months to five years of age with isolated femoral shaft fractures requiring intervention at one institution. Descriptive statistics and Wilcoxon Rank-Sum or Fisher'sFisher's Exact test were used to assess differences between OR and ER groups for either continuous or categorical variables, respectively. The electronic medical record was then queried for demographic information, location of spica cast placement, hours in the hospital, and amount and type of analgesic medications administered and prescribed. Results Overall, we noted a preponderance of femur fractures in young males (72%), with the mean age of our cohort being 2.3 years old. Our patients spent a median of 20.9 hours in the hospital and had a median worst pain score of 7/10 during their hospital stay. No difference was found between standardized amounts of morphine equivalent administration between groups in the hospital. Upon discharge from the hospital, most patients received opioid and acetaminophen prescriptions (72% and 83%), but few received an ibuprofen prescription (24.4%). More spica casts placed in the ER needed to be revised in the OR compared to spica casts placed in the OR (57% vs. 8%, p<0.01). Conclusions There are various medication regimens for patients with femoral shaft fractures treated with spica casting at one institution. Our study revealed that patients received more prescription opioids if treated in the OR. Additionally, spica casting in the ER did not significantly decrease hospital stay, and it significantly increased the risk of needing a reduction in the OR in our institution.

A Description of Children Dependent on Long Term Ventilation via Tracheostomy and Their Hospital Resource Use.

PURPOSE: To describe the proportion of children with an index hospitalization in 2014 who had established long-term invasive ventilator dependence (LTVD), and determine regional variation in hospital length of stay, charges, and readmissions. DESIGN AND METHODS: Multicenter, longitudinal, retrospective cohort study using a recently established algorithm to identify children with LTVD from the Pediatric Health Information System database with an index hospitalization at least once during 2014, excluding normal newborn care or chemotherapy, and the subset with established LTVD. Hospitals were grouped by geographic regions. Analysis included descriptive statistics and multi-variable mixed modeling for length of stay, charges, and readmissions. RESULTS: Of the 615,883 unique children discharged from 45 children's hospitals in 2014, 2235 (0.4%) had established LTVD. Of these, 342 (15%) were hospitalized in the Northeast, 677 (30%) Midwest, 733 (32%) South and 481 (22%) West. Most had at least two complex chronic conditions (97%) and used a medical device for at least two body systems (71%). No statistically significant regional variation was found for length of stay, charges, or readmissions after adjustment for child demographics, admission type, disposition, primary diagnosis, ICU stay, and number of chronic conditions. CONCLUSIONS: This study characterized the population of children with LTVD hospitalized in 2014. No regional variation was found for length of stay, charges, or readmissions. PRACTICE IMPLICATIONS: Children with established LTVD make up a small subset of all children admitted to children's hospitals however, they require substantial, costly, multifaceted care as most have additional complex chronic conditions and require multiple medical devices.

Disparity in Nurse Discharge Communication for Hospitalized Families Based on English Proficiency.

OBJECTIVES: Effective communication is critical for safely discharging hospitalized children, including those with limited English proficiency (LEP), who are at high risk of reuse. Our objective was to describe and compare the safety and family centeredness of nurse communication at hospital discharge for English-proficient (EP) and LEP families. METHODS: In this single-center, cross-sectional study, we used direct observation of hospital discharges for EP and LEP children. Observers recorded quantitative and qualitative details of nurse-family communication, focusing on 3 domains: safe discharge, family centeredness, and family engagement. Patient characteristics and percentages of encounters in which all components were discussed within each domain were compared between EP and LEP encounters by using Fisher's exact tests. We used field notes to supplement quantitative findings. RESULTS: We observed 140 discharge encounters; 49% were with LEP families. Nurses discussed all safe discharge components in 31% of all encounters, most frequently omitting emergency department return precautions. Nurses used all family-centered communication components in 11% and family-engagement components in 89% of all encounters. Nurses were more likely to discuss all components of safe discharge in EP encounters when compared with LEP encounters (53% vs 9%; P < .001; odds ratio: 11.5 [95% confidence interval 4.4-30.1]). There were no differences in family centeredness or family engagement between LEP and EP encounters. CONCLUSIONS: Discharge encounters of LEP patients were less likely to include all safe discharge communication components, compared with EP encounters. Opportunities to improve nurse-family discharge communication include providing written discharge instructions in families' primary language, ensuring discussion of return precautions, and using teach-back to optimize family engagement and understanding.

Effect of Parental Adverse Childhood Experiences and Resilience on a Child's Healthcare Reutilization.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with poor health outcomes in adults. Resilience may mitigate this effect. There is limited evidence regarding how parents' ACEs and resilience may be associated with their children's health outcomes. OBJECTIVE: To determine the association of parental ACEs and resilience with their child's risk of unanticipated healthcare reutilization. DESIGN, SETTING, AND PARTICIPANTS: We conducted a prospective cohort study (August 2015 to October 2016) at a tertiary, freestanding pediatric medical center in Cincinnati, Ohio. Eligible participants were English-speaking parents of children hospitalized on a Hospital Medicine or Complex Services team. A total of 1,320 parents of hospitalized children completed both the ACE questionnaire and the Brief Resilience Scale Survey. EXPOSURE: Number of ACEs and Brief Resilience Scale Score among parents. MAIN OUTCOMES: Unanticipated reutilization by children, defined as returning to the emergency room, urgent care, or being readmitted to the hospital within 30 days of hospital discharge. RESULTS: In adjusted analyses, children of parents with 4 or more ACEs had 1.69-times higher odds (95% CI, 1.11-2.60) of unanticipated reutilization after an index hospitalization, compared with children of parents with no ACEs. Resilience was not significantly associated with reutilization. CONCLUSION: Parental history of ACEs is strongly associated with higher odds of their child having unanticipated healthcare reutilization after a hospital discharge, highlighting an intergenerational effect. Screening may be an important tool for outcome prediction and intervention guidance following pediatric hospitalization.

Nurse Responses to Physiologic Monitor Alarms on a General Pediatric Unit.

BACKGROUND: Hospitalized children generate up to 152 alarms per patient per day outside of the intensive care unit. In that setting, as few as 1% of alarms are clinically important. How nurses make decisions about responding to alarms, given an alarm's low specificity for detecting clinical deterioration, remains unclear. OBJECTIVE: Our objective was to describe how bedside nurses think about and act upon monitor alarms for hospitalized children. DESIGN, SETTING, PARTICIPANTS: This was a qualitative study that involved the direct observation of nurses working on a general pediatric unit at a large children's hospital. MEASUREMENTS: We used a structured tool that included predetermined categories to assess nurse responses to monitor alarms. Data on alarm frequency and type were pulled from bedside monitors. RESULTS: We conducted 61.3 patient-hours of observation with nine nurses, in which we documented 207 nurse responses to patient alarms. For 67% of alarms heard outside of the room, the nurse decided not to respond without further assessment. Nurses most commonly cited reassuring clinical context (eg, medical team in room), as the rationale for alarm nonresponse. The nurse deemed clinical intervention necessary in only 14 (7%) of the observed responses. CONCLUSION: Nurses rely on clinical and contextual details to determine how to respond to alarms. Few of the alarm responses in our study resulted in a clinical intervention. These findings suggest that multiple system-level and educational interventions may be necessary to improve the efficacy and safety of continuous monitoring.

Power of a Learning Network in Congenital Heart Disease.

BACKGROUND: The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) formed to improve outcomes in infants with hypoplastic left heart syndrome. The collaborative sought to (1) decrease mortality, (2) reduce growth failure, and (3) reduce hospital readmissions due to major medical problems during the interstage period between discharge following stage 1 palliation (S1P) and admission for stage 2 palliation (S2P). METHODS: The NPC-QIC is a learning network, coproduced by parents and clinicians, of 65 pediatric cardiology centers that contribute clinical data on care processes and outcomes to a shared registry. The adapted Breakthrough Series Model structure brings teams together regularly to review data, share lessons, and plan improvements. Outcomes are monitored using statistical process control methods. RESULTS: Between 2008 and 2016, interstage mortality decreased by >40%, from 9.5% to 5.3%. Identification and use of a nutrition bundle led to improved infant growth, with a 28% reduction in interstage growth failure. The rate of serious hospital readmissions was low and did not significantly change. Importantly, a formed partnership with the parent group Sisters by Heart fostered the coproduction of tools and strategies and an emphasis on data transparency and outcomes. CONCLUSIONS: The NPC-QIC's initial efforts led to improvements in interstage growth and mortality. The NPC-QIC has modeled the use of data for improvement and research, the value of coproduction with parents, and the concept "all teach, all learn," demonstrating the power of the learning network model.

Identifying best practices in interstage care: using a positive deviance approach within the National Pediatric Cardiology Quality Improvement Collaborative.

IntroductionTo identify interstage best practices associated with lower mortality, we studied National Pediatric Cardiology Quality Improvement Collaborative centres registry using a positive deviance approach. METHODS: Positive deviant and control centre team members were interviewed to identify potential interstage best practices. Subsequently, all collaborative centres were surveyed on the use of these practices to test their associations with centre mortality. Questionnaires were scored using Likert scales; the overall score was linearly transformed to a 0-100-point scale with higher scores indicating increased use of practices. Mortality was based on patients enrolled after a centre's first year in the collaborative. Centre mortality rates were divided into tertiles. Survey scores for the low mortality tertile were compared with the other tertiles. RESULTS: For this study, seven positive deviant and four control teams were interviewed. A total of 20 potential best practices were identified, including team composition, improvement practices, and parent involvement. Questionnaires were completed by 36/43 eligible centres, providing 1504 patients for analysis. Average survey score was 50.2 (SD 13.4). Average mortality was 6.1% (SD 4.1). There was no correlation between survey scores and mortality (r=0.14, p=0.41). The one practice associated with the low mortality tertile was frequency of discussion of interstage results: 58.3% of low mortality teams discussed results at least monthly versus 8.4% of the middle and high tertile centres (p=0.02). CONCLUSIONS: Low-mortality centres more frequently discuss interstage results than high-mortality centres. Heightened awareness of outcomes may influence practice; however, further study is needed to understand the variation in outcomes across centres.

Guideline Adoption for Community-Acquired Pneumonia in the Outpatient Setting.

BACKGROUND: The Pediatric Infectious Diseases Society and Infectious Diseases Society of America national childhood community-acquired pneumonia (CAP) guideline encouraged the standard evaluation and treatment of children who were managed as outpatients. Our objectives were to (1) increase adherence to guideline-recommended diagnostics and antibiotic treatment of CAP at 5 pediatric primary care practices (PPCPs) by using quality-improvement methods and (2) evaluate the association between guideline adherence and unscheduled follow-up visits. METHODS: Immunocompetent children >3 months of age with no complex chronic conditions and who were diagnosed with CAP were eligible for inclusion in this stepped-wedge study. Interventions were focused on education, knowledge of colleagues' prescribing practices, and feedback sessions. Statistical process control charts were used to assess changes in recommendations and antibiotic treatment. Unscheduled follow-up visits were compared across time by using generalized estimating equations that were clustered by PPCP. RESULTS: CAP was diagnosed in 1906 children. Guideline recommended therapy and pulse oximetry use increased from a mean baseline of 24.9% to a mean of 68.0% and from 4.3% to 85.0%, respectively, over the study period. Among children >5 years of age, but not among those who were younger, the receipt of guideline recommended antibiotics, as compared with nonguideline therapy, was associated with the increased likelihood of unscheduled follow-up (adjusted odds ratio, 2.12; 95% confidence interval: 1.31-3.43). Chest radiographs and complete blood cell counts were rarely performed at baseline. CONCLUSIONS: Recommendations for limited use of chest radiographs and complete blood cell counts and standardized antibiotic therapy in children is supported at PPCPs. However, the guideline may need to include macrolide monotherapy as appropriate antibiotic therapy for older children.

Effects of a 1-Time Nurse-Led Telephone Call After Pediatric Discharge: The H2O II Randomized Clinical Trial.

Importance: Families often struggle after discharge of a child from the hospital. Postdischarge challenges can lead to increased use of urgent health care services. Objective: To determine whether a single nurse-led telephone call after pediatric discharge decreased the 30-day reutilization rate for urgent care services and enhanced overall transition success. Design, Setting, and Participants: This Hospital-to-Home Outcomes (H2O) randomized clinical trial included 966 children and adolescents younger than 18 years (hereinafter referred to as children) admitted to general medicine services at a free-standing tertiary care children's hospital from May 11 through October 31, 2016. Data were analyzed as intention to treat and per protocol. Interventions: A postdischarge telephone call within 4 days of discharge compared with standard discharge. Main Outcomes and Measures: The primary outcome was the 30-day reutilization rate for urgent health care services (ie, unplanned readmission, emergency department visit, or urgent care visit). Secondary outcomes included additional utilization measures, as well as parent coping, return to normalcy, and understanding of clinical warning signs measured at 14 days. Results: A total of 966 children were enrolled and randomized (52.3% boys; median age [interquartile range], 2.4 years [0.5-7.8 years]). Of 483 children randomized to the intervention, the nurse telephone call was completed for 442 (91.5%). Children in the intervention and control arms had similar reutilization rates for 30-day urgent health care services (intervention group, 77 [15.9%]; control group, 63 [13.1%]; P = .21). Parents of children in the intervention group recalled more clinical warning signs at 14 days (mean, 1.8 [95% CI, 1.7-2.0] in the intervention group; 1.5 [95% CI, 1.4-1.6] in the control group; ratio of intervention to control, 1.2 [95% CI, 1.1-1.3]). Conclusions and Relevance: Although postdischarge nurse contact did not decrease the reutilization rate of postdischarge urgent health care services, this method shows promise to bolster postdischarge education. Trial Registration: ClinicalTrials.gov Identifier: NCT02081846.

Identification of hospitalized tracheostomy and ventilator dependent patients in administrative data.

BACKGROUND: Patients with established tracheostomy and ventilator dependence are hospitalized more frequently and use more healthcare resources than other patients with complex chronic conditions. However, data to compare variation in hospitalization and resource use among patients in this population across the United States is deficient, partly due to the lack of structured methods to query national databases. AIM: Determine the best method for identifying the subset of children with established tracheostomy and ventilator dependence in Pediatric Health Information System (PHIS). HYPOTHESIS: A combination of identifiable characteristics coded in the PHIS database can be used to identify the population of patients with established tracheostomy and ventilator dependence who are admitted to the hospital. METHODS: This cross-sectional, retrospective cohort study used established methods to extract data from PHIS and assessed the sensitivity and specificity of an algorithm to identify patients with established tracheostomy and ventilator dependence as compared with a local registry of ventilator dependent patients. RESULTS: A newly created algorithm identified >90% of the 157 patients with established tracheostomy and ventilator dependence hospitalized at our organization during 2014. The sensitivity and specificity of the algorithm to identify these patients was 91% and 99%, respectively. CONCLUSIONS: This new algorithm can be used to reliably identify and further study healthcare utilization by this population of patients with established tracheostomy and ventilator dependence. In addition, future work can determine the applicability of this algorithm to other administrative datasets.

Physiologic Monitor Alarm Rates at 5 Children's Hospitals.

Alarm fatigue has been linked to patient morbidity and mortality in hospitals due to delayed or absent responses to monitor alarms. We sought to describe alarm rates at 5 freestanding children's hospitals during a single day and the types of alarms and proportions of patients monitored by using a point-prevalence, cross-sectional study design. We collected audible alarms on all inpatient units and calculated overall alarm rates and rates by alarm type per monitored patient per day. We found a total of 147,213 alarms during the study period, with 3-fold variation in alarm rates across hospitals among similar unit types. Across hospitals, onequarter of monitored beds were responsible for 71%, 61%, and 63% of alarms in medical-surgical, neonatal intensive care, and pediatric intensive care units, respectively. Future work focused on addressing nonactionable alarms in patients with the highest alarm counts may decrease alarm rates.

Piloting a Statewide Home Visiting Quality Improvement Learning Collaborative.

Objective To pilot test a statewide quality improvement (QI) collaborative learning network of home visiting agencies. Methods Project timeline was June 2014-May 2015. Overall objectives of this 8-month initiative were to assess the use of collaborative QI to engage local home visiting agencies and to test the use of statewide home visiting data for QI. Outcome measures were mean time from referral to first home visit, percentage of families with at least three home visits per month, mean duration of participation, and exit rate among infants <6 months. Of 110 agencies, eight sites were selected based on volume, geography, and agency leadership. Our adapted Breakthrough Series model included monthly calls with performance feedback and cross-agency learning. A statewide data system was used to generate monthly run charts. Results Mean time from referral to first home visit was 16.7 days, and 9.4% of families received ≥3 visits per month. Mean participation was 11.7 months, and the exit rate among infants <6 months old was 6.1%. Agencies tested several strategies, including parent commitment agreements, expedited contact after referral, and Facebook forums. No shift in outcome measures was observed, but agencies tracked intermediate process changes using internal site-specific data. Agencies reported positive experiences from participation including more frequent and structured staff meetings. Conclusions for Practice Within a pilot QI learning network, agencies tested and measured changes using statewide and internal data. Potential next steps are to develop and test new metrics with current pilot sites and a larger collaborative.

Increasing Physical Exam Teaching on Family-Centered Rounds Utilizing a Web-Based Tool.

INTRODUCTION: Millennial trainees prefer innovative, multimodal education on topics including the physical exam (PE). Attendings inconsistently meet these needs on family-centered rounds. To enhance PE teaching, a Web site (PEToolkit) was created, but its use was infrequent. We aimed to increase PEToolkit use from 2 to 5 page counts per week in 7 months. METHODS: This quality improvement project took place at a large academic center in 1 Hospital Medicine team. Key drivers informed interventions, and an annotated run chart tracked progress. We tracked secondary measures, including changes in perception of teaching skill among attendings and resident-observed methods of PE teaching, through survey methodology. RESULTS: Median page counts increased to 5 counts per week in 7 months. The most impactful interventions included training senior residents to teach with the PEToolkit Web site and team feedback on Web site usage midweek. Survey responses from 37 attendings showed that those with more exposure to PEToolkit had increased self-perceived skill of PE teaching (P = 0.02). Survey responses from 52 residents showed that those on the intervention team reported more use of video for PE teaching (P < 0.001) and higher frequency of PE teaching (P = 0.02), compared with those on the nonintervention team. CONCLUSIONS: We increased PEToolkit Web site use during family-centered rounds, thereby emphasizing the importance of PE teaching in this setting in an innovative way. Engagement of learners, frequent feedback, and coaching should be considered when incorporating technology in teaching.

Digoxin Use Is Associated With Reduced Interstage Mortality in Patients With No History of Arrhythmia After Stage I Palliation for Single Ventricle Heart Disease.

BACKGROUND: Interstage mortality (IM) remains significant after stage 1 palliation (S1P) for single-ventricle heart disease (SVD), with many deaths sudden and unexpected. We sought to determine whether digoxin use post-S1P is associated with reduced IM, utilizing the multicenter database of the National Pediatric Cardiology Quality Improvement Collaborative (NPCQIC). METHODS AND RESULTS: From June 2008 to July 2013, 816 infants discharged after S1P from 50 surgical sites completed the interstage to stage II palliation, transplant, or IM. Arrhythmia during S1P hospitalization or discharge on antiarrhythmic medications were exclusions (n=270); 2 patients were lost to follow-up. Two analyses were performed: (1) propensity-score adjusted logistic regression with IM as outcome and (2) retrospective cohort analysis for patients discharged on digoxin versus not, matched for surgical site and other established IM risk factors. Of 544 study patients, 119 (21.9%) were discharged on digoxin. Logistic regression analysis with propensity score, site-size group, and digoxin use as predictor variables showed an increased risk of IM in those not discharged on digoxin (odds ratio, 8.6; lower confidence limit, 1.9; upper confidence limit, 38.3; P<0.01). The retrospective cohort analysis for 60 patients on digoxin (matched for site of care, type of S1P, post-S1P ECMO use, genetic syndrome, discharge feeding route, ventricular function, tricuspid regurgitation, and aortic arch gradient) showed 0% IM in the digoxin at discharge group and an estimated IM difference between the 2 groups of 9% (P=0.04). CONCLUSIONS: Among SVD infants in the NPCQIC database discharged post-S1P with no history of arrhythmia, use of digoxin at discharge was associated with reduced IM.

Risk Factors for Unanticipated Readmissions During the Interstage: A Report From the National Pediatric Cardiology Quality Improvement Collaborative.

This study describes unanticipated interstage readmissions in patients with hypoplastic left heart syndrome, identifies independent risk factors for unanticipated interstage readmissions, and evaluates variation in unanticipated readmission rates among collaborative centers. Retrospective data of patients enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry from July 2008 to July 2013 were analyzed. Risk factors present at the beginning of the interstage were captured. Competing risks time to event analyses determined the association between these factors and unanticipated interstage readmission. Readmission center variation was examined using funnel plots. Unanticipated interstage readmissions occurred in 66% of 815 patients at 50 centers. The median readmission length of stay was 2 days (interquartile range: 0-6) and median time to first readmission was 29 days (interquartile range: 9-63). Most readmissions were prompted by minor changes in clinical status (64%), whereas only 6% were major adverse event readmissions. Independent readmission risk factors included genetic syndrome (HR = 1.40, 95% CI: 1.05-1.88), center volume (small vs large HR = 1.32, CI: 1.04-1.66, medium vs large HR = 1.35, CI: 1.09-1.68), preoperative ventricular dysfunction (HR = 2.02, CI: 1.31-3.10), tricuspid regurgitation (HR = 1.36, CI: 1.08-1.72), duration of circulatory arrest (HR = 0.99, CI: 0.989-0.998), and undergoing Hybrid procedure relative to Norwood/right ventricle to pulmonary artery conduit (HR = 1.40, CI: 1.02-1.93). There was significant center variation in the number of readmissions and duration of readmissions. Unanticipated readmissions are common during the interstage period with notable center variation. However, these readmissions are short and are rarely in response to major adverse events.