A Catholic Perspective on COVID-19.

It took nearly two thousand years for society to recognize the Hippocratic insistence that "the doctor knows best"1 was an inadequate approach to medical decisionmaking. Today, patient-centered medicine has come to understand that the individual patient has a significant role in the decisionmaking process.2.

Standardizing the Evaluation and Management of Necrotizing Enterocolitis in a Level IV NICU.

OBJECTIVES: Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. METHODS: A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. RESULTS: Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. CONCLUSIONS: Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.

Diagnostic Yield of Cardiac Biomarker Testing in Predicting Cardiac Disease and Multisystem Inflammatory Syndrome in Children in the Pandemic Era.

OBJECTIVES: This study aimed to assess whether elevations in cardiac biomarkers are associated with pediatric cardiac diagnoses in the era of COVID-19 and multisystem inflammatory syndrome in children (MIS-C). STUDY DESIGN: This single-center retrospective study analyzed children with a troponin drawn in the emergency department or inpatient unit between April 21 and December 31, 2020. The primary outcome was the presence of a cardiac diagnosis or MIS-C. Relationships among demographics, complaint, cardiac diagnostics, and cardiac biomarkers were analyzed. RESULTS: Four hundred eighty-six patients (mean ± SD; age 13.1 ± 7.8 years; 46.7% women) met inclusion criteria, for whom a cardiac diagnosis (excluding MIS-C) was made in 27 (5.6%) patients, with MIS-C diagnosed in 14 (2.9%) patients. The sensitivity and specificity of an elevated initial high-sensitivity troponin T (hsTropT) value (>14 ng/L) in predicting the composite outcome of a cardiac diagnosis or MIS-C were 54% and 89%, respectively. Four percent of patients with negative initial troponin values were found to have a cardiac diagnosis or MIS-C. Multivariable regression analysis demonstrated that elevated hsTropT (>14 ng/L; odds ratio [OR] [95% confidence interval]: 4.9 [1.70-14.0]) and elevated N-terminal pro B-type natriuretic peptide values (>500 pg/mL; 6.4 [2.01-20.1]) were associated with increased odds of a cardiac diagnosis or MIS-C. CONCLUSIONS: Children with elevated cardiac biomarkers have increased odds of a cardiac diagnosis or MIS-C and warrant workup regardless of indication for testing. Although a negative hsTropT may reassure providers, further investigation is critical in developing algorithms to reliably exclude cardiac disease.

Informed consent is poorly documented when obtaining toxicology testing at delivery in a Massachusetts cohort.

BACKGROUND: Positive toxicology testing at delivery can have enormous consequences for birthing persons and their families, including charges of child abuse or neglect and potential loss of custody for the birthing parent. Therefore state and national guidelines stipulate that, clinicians must obtain consent before toxicology testing at delivery. OBJECTIVE: This study aimed (1) to determine clinician documentation of patient consent for peripartum toxicology testing and (2) to characterize the extent to which patient and hospital characteristics were associated with documented consent. STUDY DESIGN: This was a retrospective cohort of individuals who underwent toxicology testing within 96 hours of delivery between April 2016 and April 2020 at 5 affiliated hospitals across Massachusetts. Medical records were reviewed for documentation of clinician intent to obtain maternal toxicology, testing indication, verbal consent to testing, and child protective services involvement. Hierarchical multivariable logistic regression was used to examine the association between patient and hospital characteristics and documentation of verbal consent. RESULTS: Among 60,718 deliveries, 1562 maternal toxicology tests were obtained. Verbal consent for testing was documented in 466 cases (29.8%). Documented consent was lacking across most demographic groups. Consent was no more likely to be documented when a report was filed with child protective services and less likely in cases where the birthing parent lost custody before discharge (P=.003). In our multivariable model, consent was least likely to be documented when a maternal complication (abruption, hypertension, preterm labor, preterm premature rupture of membranes, or intrauterine fetal demise) was the indication for testing (adjusted odds ratio, 0.46; 95% confidence interval, 0.28-0.76). Verbal consent was twice as likely to be documented in delivery hospitals with established consent policies (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.37). CONCLUSION: Consent for toxicology testing at delivery seemed to be infrequently obtained on the basis of clinician documentation. Provider education and hospital policies for obtaining informed consent are needed to protect the rights of birthing individuals.

Operational Innovation in the Provision of Pediatric Extracorporeal Membrane Oxygenation for Multisystem Inflammatory Syndrome in Children.

Treatment of multisystem inflammatory syndrome in children (MIS-C) can require significant critical care resources. Our aim is to alert mixed pediatric and adult hospitals worldwide of the possibility that pediatric and adult patients may simultaneously require cannulation to extracorporeal membrane oxygenation (ECMO) for MIS-C and severe COVID-19. We conducted a retrospective review of operations required to treat cardiogenic shock in 3 pediatric patients with a diagnosis of MIS-C admitted to a single medium-sized pediatric referral center located within a large academic medical center over a 14-day period. At this time, a large number of adult patients required ECMO for severe COVID-19 at our institution. Of the 11 pediatric patients who presented with MIS-C during the first surge of 2020, 2 patients required cannulation to venoarterial extracorporeal membrane oxygenation (VA-ECMO), and a third patient developed a life-threatening arrhythmia requiring transfer to a neighboring institution for consideration of VA-ECMO when our institution's ECMO capacity had briefly been reached. Pediatric referral centers located within institutions providing ECMO to adult patients with severe COVID-19 may benefit from frequent and direct communication with their adult and regional colleagues to devise a collaborative plan for safe and timely provision of ECMO to patients with MIS-C as the ongoing pandemic continues to consume this limited, lifesaving resource.

A Case of Airway Compromise in a 15-year-old Girl With Intellectual Disability.

Foreign body ingestion (FoBI) is an important source of morbidity and mortality in the pediatric population. Patients with intellectual disabilities (ID) are at increased risk of FoBI, likely due to the known association between ID and increased rates of pica. In this report, we present the case of a 15-year-old female patient with autism spectrum disorder (ASD) and ID who presented to the emergency department with fever, drooling, and respiratory failure. She required intubation for airway management. A diagnosis of FoBI was made after striking CT images revealed an entire graphite pencil in her esophagus, causing perforation of the retropharyngeal space. Her recovery course was complicated. Shortly after discharge, the patient was readmitted with repeat FoBI and another significant esophageal injury. Patients with ID who require surgery due to FoBI are at higher risk of complications and often require prolonged hospitalizations compared to their neurotypical peers. Prevention of FoBI in patients with ID constitutes an important aspect of clinical care and requires efforts toward achieving a balance between patient safety and autonomy.

Distinguishing Features of Patients Evaluated for Multisystem Inflammatory Syndrome in Children.

OBJECTIVES: Given the significant overlap of multisystem inflammatory syndrome in children (MIS-C) with other common childhood illnesses presenting to the emergency department, extensive workup of this syndrome has become necessary. Nevertheless, little has been published on the factors differentiating MIS-C from other conditions in the acute care setting. We investigated differences in presentation and laboratory studies between suspected versus confirmed MIS-C patients. METHODS: This was a retrospective cohort study on patients 21 years or younger undergoing investigation for possible MIS-C at a single institution between April 21 and July 1, 2020. The primary outcome was diagnosis of MIS-C or an alternative final diagnosis. Clinical features and laboratory findings from initial presentation were collected and analyzed. RESULTS: A total of 106 patients (median, 4 years; 55.7% male) were included, of whom 17 (16%) of 106 met the criteria for MIS-C. Multisystem inflammatory syndrome in children patients were significantly more likely to report a coronavirus disease 2019 exposure (odds ratio (OR), 13.17 [3.87-44.9]), have gastrointestinal symptoms (OR, 3.81 [1.02-14.19]), and have a significantly higher odds of having abnormal laboratory values including high-sensitivity troponin T (OR, 13 [4.0-42.2]), N-terminal B-type natriuretic peptide (OR, 8.4 [2.3-30.1]), D-dimer (OR, 13 [1.6-103]), and ferritin (OR, 7.8 [2.2-27.2]). There were also differences between groups in inflammatory markers: C-reactive protein (median, 134.45 mg/L vs 12.6 mg/L; P < 0.05) and procalcitonin (1.71 ng/mL vs 0.14 ng/mL; P < 0.001). CONCLUSIONS: Higher elevations in key laboratory studies may help to distinguish between MIS-C patients and non-MIS-C patients presenting to the emergency department.

Improving Pediatric Residents' Screening for Access to Firearms in High-Risk Patients Presenting to the Emergency Department.

BACKGROUND/OBJECTIVE: Access to a firearm is a significant risk for completed suicide or homicide. We sought to increase the rate of screening for access to firearms in patients who presented to the emergency department with suicidal or homicidal ideation or suicide attempt through the use of quality improvement methodology. METHODS: Patient records were eligible for inclusion if the child was under the age of 19 and presented to the emergency room of our tertiary medical center with a diagnosis of suicidal ideation, homicidal ideation, or suicide attempt. Records were manually reviewed for demographic information and documentation of screening for access to firearms. A baseline survey of the pediatric residents was completed to identify perceived barriers to screening for access to firearms. Subsequently, three "Plan, Do, Study, Act" (PDSA) cycles consisting of a noon conference, a dedicated grand rounds, and an electronic health record template were completed. RESULTS: During the baseline and study period, 501 patients met inclusion criteria. Forty-one of sixty-six (62.1%) residents completed a baseline survey and identified barriers to screening. There was no significant increase in screening following the first or second PDSA cycles. Following the third PDSA cycle, screening rates increased from 4% to 34%. CONCLUSIONS: Quality improvement methodology can be used to increase the rates of screening for access to firearms in high-risk patients. Further work is necessary to identify additional strategies to further increase screening rates.

Adult COVID-19 Patients Cared for in a Pediatric ICU Embedded in a Regional Biothreat Center: Disease Severity and Outcomes.

The objective of this study was to describe the clinical characteristics and outcomes of adult coronavirus disease 2019 (COVID-19) patients admitted to a pediatric intensive care unit (PICU), with assessment of respiratory clinical severity and outcomes when cared for by pediatric intensivists utilizing specific care processes. We conducted a retrospective cohort study of adult patients admitted to the 14-bed PICU of a quaternary referral center during the COVID-19 surge in Boston between April and June 2020. A total of 37 adults were admitted: 28 tested COVID-19 positive and 9 tested COVID-19 negative. Of the COVID-19-positive patients, 21 (75%), were male and 12 (60.7%) identified as Hispanic/Latino. Comorbidities in the patients included diabetes mellitus (39.3%), hyperlipidemia (39.3%), and hypertension (32.1%). Twenty-four (85.7%) required mechanical ventilation, in whom the lowest median ratio of arterial oxygen partial pressure to fractional inspired pressure was 161.5 (141.0 to 184.5), the median peak positive end-expiratory pressure (PEEP) was 14 (12.0 to 15.8) cmH2O and 15 (62.5%) underwent an optimal PEEP maneuver. Twelve (50%) patients were proned for a median of 3.0 (3.0 to 4.8) days. Of the 15 patients who were extubated, 3 (20%) required reintubation. Tracheostomy was performed in 10 patients: 3 after extubation failure and 7 for prolonged mechanical ventilation and weakness. Renal replacement therapy was required by 4 (14.3%) patients. There were 2 (7.1%) mortalities. We report detailed clinical outcomes of adult patients when cared for by intact pediatric critical care teams during the COVID-19 pandemic. Good clinical outcomes, when supported by adult critical care colleagues and dedicated operational processes are possible.

Impact of Clinical Process Improvement Training in an Integrated Delivery System.

Multiple integrated health systems use frontline staff training in quality and process improvement, although the optimal method to determine training success remains unknown. The authors assessed the Partners Clinical Process Improvement Leadership Program's short-term impact by evaluating data in project presentations during 14 courses between 2010 and 2016. Long-term impact was assessed via a graduate survey. Among 262 interprofessional teams, 180 (69%) achieved short-term improvement, including 78 (30%) achieving and 102 (39%) demonstrating improvement toward their project goal. Projects implementing ≥2 interventions were more likely to succeed. Of 231 graduates surveyed, 79% reported the ability to lead and 67% reported actual work on additional quality improvement projects. Ninety-seven percent of alumni reported a positive career impact. Hospital leadership support of clinical process improvement training meets short-term improvement needs and promotes long-term capacity for learning health systems.

Controversy About Withdrawal of Postresuscitation Care After Cardiac Arrest.

With increasing focus in the last decade on post-cardiac arrest care in pediatrics, return of spontaneous circulation, survival rates, and neurologic outcome have improved. As part of this postarrest care, both the American Heart Association and the American Academy of Neurology state it is reasonable to consider targeted temperature management in pediatric comatose patients, although this care is challenging and time sensitive, with many gaps in knowledge remaining. Many pediatric patients will still not survive or will suffer severe neurocognitive impairment despite the therapeutic arsenal provided. Adult guidelines suggest providing postarrest supportive care and limiting prognosis discussions with families until after 72 hours of therapy, but pediatric clinicians are advised to consider a multitude of factors given the lack of data. What, then, should clinicians do if family members of a patient who has been resuscitated request the withdrawal of all life support in the 24 hours immediately postarrest? In this Ethics Rounds, we present such a case and the responses of different clinicians and bioethicists.

From Death to Life: Ethical Issues in Postmortem Sperm Retrieval as a Source of New Life.

This paper examines and critiques the ethical issues in postmortem sperm retrieval and the use of postmortem sperm to create new life. The article was occasioned by the recent request of the parents of a West Point cadet who died in a skiing accident at the Academy to retrieve and use his sperm to honor his memory and perpetuate the family name. The request occasioned national media attention. A trial court judge in New York in a two-page order authorized both the retrieval and use of the postmortem sperm.

Going green: decreasing medical waste in a paediatric intensive care unit in the United States.

The healthcare industry generates significant waste and carbon emissions that negatively impact the environment. Intensive care units (ICU) are a major contributor to the production of waste, due to patient complexity and needs requiring extensive equipment, cleaning practices and pre-emptive supplies. To quantify the extent of the problem, health care professionals collected all unused medical supplies destined to be discarded over three one-week periods in a paediatric intensive care unit, weighed the items, and created an inventory. This article argues for greener hospital standards and provides a specific example of a project framework to reduce disposable waste with the hope that others can embark on similar initiatives for a more ethical and sustainable future for hospitals. Healthcare facilities must not just meet short-sighted safety standards of the now. In order to be a virtuous organization, one must consider all implications of daily decisions, including disposable supplies and cleaning.