Creating a health equity and inclusion office in an academic pediatric medical center: priorities addressed and lessons learned.

BACKGROUND: Over the last two decades, medical schools and academic health centers have acknowledged the persistence of health disparities in their patients and the lack of diversity in their faculty, leaders and extended workforce. We established an Office of Health Equity and Inclusion (OHEI) at our pediatric academic medical center after a thorough evaluation of prior diversity initiatives and review of faculty development data. OBJECTIVE: To describe the lessons learned at a pediatric academic medical center in prioritizing and implementing health equity, diversity and inclusion (EDI) initiatives in creating the OHEI. MATERIALS AND METHODS: We reviewed internal administrative data and faculty development data, including data related to faculty who are underrepresented in medicine, to understand the role of our EDI initiatives in the strategic priorities addressed and lessons learned in the creation of the OHEI. RESULTS: The intentional steps taken in our medical center's strategic approach in the creation of this office led to four important lessons to improve pediatric health equity: (1) board, senior executive and institutional prioritization of EDI initiatives; (2) multi-specialty and interprofessional collaboration; (3) academic approach to EDI programmatic development; and (4) intentionality with accountability in all EDI initiatives. CONCLUSION: The key lessons learned during the creation of an Office of Health Equity and Inclusion can provide guidance to other academic health centers committed to implementing institutional priorities that focus their EDI initiatives on the improvement of pediatric health equity.

Recombinant factor seven therapy for postoperative bleeding in neonatal and pediatric cardiac surgery.

BACKGROUND: Severe bleeding is a major complication in the postoperative pediatric cardiac surgery patients. We evaluated the efficacy and safety of recombinant factor seven (rFVIIa) therapy in this patient population. METHODS: A retrospective unmatched case-control study for the previous five years in a single institution was undertaken. Patients with severe bleeding treated with rFVIIa therapy (study group) were compared with patients treated with blood products only (control group) using analysis of variance. Mediastinal bleeding, blood products transfusion, and coagulation studies before and six hours after the first dose of rFVIIa therapy were analyzed using the Student paired t test. The dose, frequency, and side-effects of rFVIIa therapy were studied. RESULTS: Forty-six patients with severe bleeding were studied. Twenty-three of 24 patients in the study group, including 12 patients placed on extracorporeal membrane oxygenation (ECMO), responded to rFVIIa therapy (mean dose 43 +/- 22.9 microg/kg/dose). There was significant reduction in chest tube drainage (from 52.3 +/- 36.1 mL/kg/hour to 18.8 +/- 20.9 mL/kg/hour, p = 0.0003) along with significant reduction of blood products transfusion (p < 0.001) in the study group patients as compared with control group patients. One patient who failed to respond had surgical bleeding. Two patients developed major thrombotic complications that included clots in the ECMO circuit and thrombosis at bleeding arterial line site resulting in limb ischemia. Four additional patients in the study group developed mediastinal clots. Overall, 25% of patients developed thrombosis after rFVIIa therapy. CONCLUSIONS: The rFVIIa therapy seems to be an effective treatment for severe bleeding in postoperative pediatric cardiac surgery patients in the absence of surgical bleeding. It must be judiciously used in patients bleeding from multiple sites or having preexistent clots in the ECMO circuit to prevent major thrombotic complications.

Insulin glargine supplementation during early management phase of diabetic ketoacidosis in children.

OBJECTIVE: To study the effect of subcutaneous administration of insulin glargine on the rate of resolution of acidosis and intravenous insulin infusion requirement in children with moderate and severe diabetic ketoacidosis (DKA). STUDY DESIGN: Retrospective cohort study. SETTING: Pediatric intensive care unit of a university-based children's hospital. PATIENTS: Children with moderate to severe DKA admitted between March 2001 and February 2003. RESULTS: The outcomes of children who received 0.3 units/kg of subcutaneous insulin glargine in the first 6 h of management in addition to the standard treatment (n=12) were compared with those of children who received standard treatment alone (n=59). Measured outcomes included dose of intravenous insulin required, duration of insulin infusion and acidosis correction time. The two groups were similar in demographics and severity of illness. The mean time for acidosis correction (venous pH>or=7.3) in the insulin glargine group was shorter than the standard therapy group (12.4+/-2.9 h and 17.1+/-6.2 h respectively, p<0.001). The insulin infusion time was shorter in the insulin glargine group (14.8+/-6.0 h vs 24.4+/-9.0 h, p<0.001). There was a trend towards shorter total hospital stay in the glargine group (3.2+/-1.0 days vs 3.72+/-1.06 days). CONCLUSIONS: In our small series of children with moderate and severe DKA, supplementing with subcutaneous insulin glargine led to a faster resolution of acidosis without any adverse effects. This could potentially lead to a shorter need for insulin infusion and a shorter ICU length of stay.

Leukopheresis therapy for severe infantile pertussis with myocardial and pulmonary failure.

OBJECTIVE: To describe an infant with severe pertussis successfully treated with leukopheresis. DESIGN: Case report. SETTING: Pediatric intensive care unit of a children's hospital. PATIENT: Five-wk-old female with pertussis complicated by cardiorespiratory failure. INTERVENTIONS: Single leukopheresis treatment. MEASUREMENTS AND MAIN RESULTS: Normalization of the white blood cell count and marked cardiorespiratory improvement after treatment; patient survived. CONCLUSION: Given the temporal association between treatment and improvement, we hypothesize that the markedly elevated white blood cell count has a major role in the cardiopulmonary compromise.

Isoflurane therapy for severe refractory status asthmaticus in children.

OBJECTIVE: To describe the use of inhaled isoflurane in a series of children with life-threatening asthma. DESIGN: Retrospective case series. SETTING: Pediatric intensive care unit of a tertiary-care children's hospital. Ten children ranging in age from 1 to 16 years with 11 episodes of severe asthma requiring invasive mechanical ventilation in the pediatric intensive care unit over a 5-year period. RESULTS: Isoflurane resulted in an improvement in arterial pH and a reduction in partial pressure of arterial carbon dioxide (PaCO(2)) in all the 11 instances. This effect was sustained in 10 cases and led to clinical improvement and rapid weaning from mechanical ventilation. One child failed to show sustained response and was placed on veno-venous extracorporeal membrane oxygenation. One child died secondary to anoxic brain injury sustained prior to hospitalization. Hypotension was the major side effect, and occurred in 8 children necessitating vasopressor support. CONCLUSIONS: Isoflurane improves arterial pH and reduces partial pressure of arterial carbon dioxide in mechanically ventilated children with life-threatening status asthmaticus who are not responsive to conventional management.

Inhaled nitric oxide use in bidirectional Glenn anastomosis for elevated Glenn pressures.

BACKGROUND: Children frequently undergo bidirectional Glenn anastomosis in the staged surgical management of single ventricle physiology. The purpose of our study was to investigate the role of inhaled nitric oxide therapy in children with marked elevations in Glenn pressures after this surgery. METHODS: A retrospective study over a 30-month period was performed. The effect of inhaled nitric oxide therapy was analyzed in children with marked elevations of Glenn pressures resulting in decreased systemic perfusion. Effects on Glenn pressures, respiratory indices, and systemic perfusion were evaluated after initiation of nitric oxide therapy and compared with baseline parameters. RESULTS: Sixteen patients were placed on nitric oxide therapy for marked elevations of Glenn pressures (22.4 +/- 3.9 mm Hg). In the 11 responsive patients, there were significant reductions in Glenn pressures (from 22.4 mm Hg to 17.1 mm Hg, p < 0.001) and significant improvement in partial pressure of oxygen to fraction of inspired oxygen ratio (from 49 to 74.3, p = 0.001) and oxygenation index (from 17 to 12, p = 0.005). There was simultaneous significant reduction in inotrope score (from 14.9 to 11.4, p < 0.001) and fluid volume support (from 11.4 mL/kg to 2.3 mL/kg, p < 0.001) in the responsive patients. Five patients that failed to show any response were found, subsequently, to have an anatomic lesion. CONCLUSIONS: Inhaled nitric oxide produces significant reduction in Glenn pressures and improvement in systemic perfusion and pulmonary gas exchange in patients with marked elevations of Glenn pressures after bidirectional Glenn anastomosis. Patients who fail to respond should be investigated for an anatomic lesion.

Clinical outcomes of 84 children with congenital heart disease managed with extracorporeal membrane oxygenation after cardiac surgery.

The purpose of our research was to study the clinical outcomes of children with congenital heart disease (CHD) requiring extracorporeal membrane oxygenation (ECMO) support after cardiac surgery at a tertiary care children's hospital. Retrospective review of all patients with CHD who required postcardiotomy ECMO between January 2001 and September 2004 (45 months) was undertaken. Various outcome predictors were tested for any association with survival to hospital discharge using univariate analysis. A total of 84 children were placed on ECMO after CHD surgery; 39 (46.4%) were placed on ECMO in the operating room. Median age of the patients was 128 days (1 day to 5 years) and median weight was 4.53 kg (2-18 kg). Active cardiopulmonary resuscitation was ongoing at the time of cannulation in 27 children (32%). Fifty-two children (61.9) survived > 24 hours after decannulation and 31 (36.9%) survived to discharge. High arterial serum lactate levels at the time of ECMO initiation were strongly correlated with nonsurvival (p = 0.004). Nonsurvivors had longer duration on ECMO than survivors (p = 0.003). The odds of survival dropped significantly after 144 hours (day 6) of ECMO. ECMO support results in improved outcomes in patients who suffered hemodynamic collapse post cardiac surgery. Underlying cardiac lesion, age, weight, gender, initial arterial pH, location of ECMO initiation, need for hemofiltration and placement of ECMO after active ongoing cardiopulmonary resuscitation did not increase the mortality risk. Initial arterial serum lactate level and inability to wean off by 6 days were strongly correlated with nonsurvival.