Improving Pediatric Hypertension Screening in an Academic Primary Care Setting.

Introduction: Adherence to the American Academy of Pediatrics clinical practice guidelines for screening and managing high blood pressure (BP) is low. This team sought to improve recognition and documentation of relevant diagnoses in patients aged 13-20 years who presented to general pediatric clinics. Methods: The primary outcome measure was the proportion of office visits for patients ages 13-20 with a BP ≥ 120/80 with a visit or problem list diagnosis of hypertension or elevated BP. Secondary measures included (1) the proportion of patients who had their BP measured in the right arm, (2) the proportion of patients who had a mid-arm circumference measurement recorded, and (3) the proportion of patients who had a second BP reading measured at the visit. Interventions addressed key drivers for evidence-based high BP screening: standard BP measurement, electronic health record clinical decision support, and clinical pathway adoption. Data were collected over a twenty-seven-month period and plotted using the Laney p' chart. Results: Provider documentation of elevated BP or hypertension improved from a baseline mean of 24% in April 2020 through January 2022 to 41% in February 2021 through June 2022. All secondary outcome measures also demonstrated significant improvement. Conclusions: This project demonstrates the feasibility of improving adherence to best practices of BP measurement in primary care clinics through education, acquisition of resources, and implementation of electronic health record flags for abnormal values.

Integrating Safe Sleep Practices into a Pediatric Hospital: Outcomes of a Quality Improvement Project.

A quality improvement project for implementing safe sleep practices (SSP) was conducted at a large, U.S children's hospital. The intervention involved education of staff and standardization of infant sleep practices utilizing a multifaceted approach. Staff surveys and environmental audits were conducted pre- and post-intervention. Safe Sleep Environment (SSE) audits showed an improvement from 23% to 34% (p<0.001) post-intervention. Staff confidence to provide education to caregivers on SSP showed a significant increase. Results from this project demonstrate a successful approach to implement SSP in the hospital setting. Infant safe sleep practices have the potential to reduce infant mortality.

Family experiences and pediatric health services use associated with family-centered rounds.

BACKGROUND: Family-centered rounds (FCR) are defined as interdisciplinary bedside teaching rounds with active family participation. The objective of this study was to examine the association of FCR with family experiences and health services use. METHODS: Prospective study comparing families with a child admitted to general pediatric inpatient services with and without FCR. The presence of FCR elements was assessed before study enrollment. Study data were obtained by an in-person interview, a follow-up phone interview <1 week after discharge, and medical record review. Family outcomes were informed by Consumer Assessment of Healthcare Providers and Systems measures. Health service use outcomes included hour of discharge, number of medications, and overall charges. Primary analyses included χ(2) and multivariate regression. Secondary analyses by using propensity score matching were performed to account for differences on observed variables. RESULTS: A total of 140 of 203 eligible families were enrolled; 97 completed follow-up surveys (49 on FCR team). Compared with non-FCR, FCR families were more likely to report consistent medical information (P < .001), the option of discussing care plan (P < .001), doctors listening carefully (P < .01), and doctors showing respect (P < .001). No differences were found in number of medications (mean 2.4 vs 2.9, P = .26) or discharge time (mean 3:06 pm versus 2:43 pm, P = .39). No difference was found for hospital charges after adjusting for length of stay outliers. CONCLUSIONS: FCR are associated with higher parent satisfaction, consistent medical information, and care plan discussion, with no additional burden to health service use. Additional studies should assess FCR under different settings of care.

Rates of enrollment in smoking cessation services following fax referrals from a children's hospital.

OBJECTIVE: The aim of this study was to describe the rates of enrollment in tobacco dependence treatment among smoking adults who accepted a fax referral from health care providers at a children's hospital, and to examine smoker characteristics associated with enrollment. METHODS: Secondary analysis of the state-sponsored fax referral and treatment program data on all referrals from Arkansas Children's Hospital in 2005 to 2007 was conducted. Enrollment was defined as attendance at 1 or more counseling sessions within 1 year of referral. Logistic regression analyses were used to identify demographic and tobacco-related characteristics associated with enrollment versus nonenrollment in a treatment program among those contacted by the program. RESULTS: Of the 749 faxed referrals to the program, 157 (21.0%) enrolled in a treatment program and received 1 or more treatment sessions; 505 were contacted by the program, and of these, 147 (29%) enrolled. Women were more likely to enroll than men (odds ratio [OR] 1.81; 95% confidence interval [95% CI], 1.09-3.01). Whites were twice as likely to enroll than African Americans (OR 2.35; 95% CI, 1.28-4.33). Older age (OR 1.04; 95% CI, 1.01-1.06) and higher self-efficacy scores (OR 1.13; 95% CI, 1.02-1.26) increased the likelihood of enrollment. CONCLUSIONS: Approximately 1 in 5 smokers who accepted a fax referral enrolled in and received intensive treatment services for tobacco dependence. Thus, innovative approaches are needed to increase enrollment among younger, African American, and male smokers.

Incorporating the ACGME educational competencies into morbidity and mortality review conferences.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) mandates that residents be trained in six core educational competencies. Practice-based learning and improvement (PBLI), one of the six competencies, is defined as the investigation and evaluation of one's own patient care. Morbidity and Mortality Conference, a frequently used venue to review the clinical outcome of hospitalized patients, provides the opportunity to teach and assess PBLI. DESCRIPTION: We report an approach to Morbidity and Mortality Conference that includes a systematic analysis of the ACGME core competencies and their application to a clinical case, a regular review of the factors that defines high-quality patient care, and a focused discussion of the PBLI competency. EVALUATION: Preliminary data indicate that our residents preferred this revised method for conducting Morbidity and Mortality Conference. CONCLUSION: Our adaptation to Morbidity and Mortality Conference provides a systematic review of the core competencies and their relevance to clinical decision making, with the ultimate goal of improving patient care.

Defining family-centered rounds.

BACKGROUND: Physicians are required to provide safe, effective, and high-quality care that is patient-centered. Continuing to meet the educational needs of residents and medical students in the setting of patient-centered care will require developing new models for hospital "work rounds." Family-centered rounds is a model of communicating and learning between the patient, family, medical professionals, and students on an academic, inpatient ward setting. Unfortunately, in the medical literature, there is no consensus on the definition of family-centered rounds. SUMMARY: Despite the increased utilization of hospitalists and the recognition that bedside teaching has many benefits, bedside rounds are underutilized. In this article, we present a description of family-centered rounds that is supported by a review of the literature on bedside teaching, family-centered care, and interdisciplinary care. The key difference between family-centered rounds and traditional bedside teaching is the active participation of the patient and family in the discussion. Interdisciplinary care implies that professionals from a variety of disciplines work collaboratively to develop a unified care plan. Family-centered rounding provides an interface between families and medical professionals that allows education of medical students and residents as well as the development of a unified care plan. CONCLUSIONS: Family-centered rounds hold potential to create a patient-centered environment, enhance medical education, and improve patient outcomes. The model is a planned, purposeful interaction that requires the permission of patients and families as well as the cooperation of physicians, nurses, and ancillary staff.

Disposition of ceftazidime after intraperitoneal administration in adolescent patients receiving continuous cycling peritoneal dialysis.

BACKGROUND: Peritonitis is the single most common complication in children maintained on continuous cycling peritoneal dialysis (CCPD) and a significant cause of morbidity. Recent consensus guidelines for the treatment of peritonitis in children receiving peritoneal dialysis recommend the combined intraperitoneal administration of ceftazidime with either a first-generation cephalosporin or vancomycin. The objective of this study is to determine whether a continuous maintenance dose of intraperitoneal ceftazidime in the absence of a loading dose would maintain adequate serum and dialysate concentrations to be effective in the treatment of peritonitis. METHODS: Five ambulatory patients on CCPD therapy were studied with continuous intraperitoneal administration of ceftazidime (125 mg/L). Blood, dialysate, and urine samples were collected at specified intervals during a 24-hour period. Ceftazidime concentrations were measured by using a high-performance liquid chromatography assay. RESULTS: Mean serum concentrations at completion of the short rapid cycles and at 24 hours were 28.92 +/- 13.64 and 23.92 +/- 11.93 microg/mL, respectively. Serum bioavailability at 24 hours was 74% +/- 6%. Mean dialysate concentrations at completion of the short rapid cycles and at 24 hours were 87.43 +/- 19.18 and 32.06 +/- 6.27 microg/mL, respectively. All 5 patients achieved serum and dialysate ceftazidime concentrations greater than the mean inhibitory concentration within 4 hours. CONCLUSION: In adolescent patients on CCPD therapy, a continuous maintenance dose of intraperitoneal ceftazidime in the absence of a loading dose achieves serum and dialysate levels greater than the mean inhibitory concentration of sensitive organisms within 4 hours that persist for 24 hours.