Implementation of a Suicide Risk Screening Clinical Pathway in a Children's Hospital: A Feasibility Study.

OBJECTIVES: Youth suicide is a pressing global concern. Prior research has developed evidence-driven clinical pathways to screen and identify suicide risk among pediatric patients in outpatient clinics, emergency departments (ED) and inpatient hospital units. However, the feasibility of implementing these pathways remains to be established. Here, we share the results of a hospital-wide "youth suicide risk screening pathway" implementation trial at an urban academic pediatric hospital to address this gap. METHODS: A 3-tier "youth suicide risk screening pathway" using The Ask Suicide-Screening Questions (ASQ) was implemented for patients aged 10 to 26 years who received care at an urban academic pediatric hospital's emergency department or inpatient units. We retrospectively reviewed implementation outcomes of this pathway from January 1 to August 31, 2019. The feasibility of this implementation was measured by assessing the pathway's degree of execution, fidelity, resource utilization, and acceptability. RESULTS: Of 4108 eligible patient encounters, 3424 (83%) completed the screen. Forty-eight (1%) screened acute positive, 263 (8%) screened nonacute positive and 3113 (91%) screened negative. Patients reporting positive suicide risk were more likely to be older and female, although more males required specialty mental health evaluations. Pathway fidelity was 83% among all positive screens and 94% among acute positive screens. The clinical pathway implementation required 16 hours of provider training time and was associated with slightly longer length of stay for inpatients that screened positive (4 vs 3 days). Sixty-five percent of nurses and 78% of social work providers surveyed supported participation in this effort. CONCLUSIONS: It is feasible to implement a youth suicide risk screening pathway without overburdening the system at an urban academic pediatric hospital.

Expediting Treatment of Seizures in the Intensive Care Nursery.

OBJECTIVES: Prolonged neonatal seizures are associated with poor neurodevelopmental outcomes. The aim of this quality improvement project was to decrease the time to medical treatment of seizures by 45% within 15 months for neonates admitted to the intensive care nursery (ICN) in an academic children's hospital. METHODS: A multidisciplinary team developed key drivers for timely treatment of seizures. Targeted interventions included optimizing a seizure rescue process with a mechanism that brings a pharmacist to the bedside for expedited medication delivery, in addition to interactive educational sessions. The outcome measure was time from the decision to treat seizures to medication administration. The process measure was use of the seizure rescue process with a balancing measure of unnecessary activations of this process. Data were collected from monthly chart review and displayed on statistical process control charts for analysis. The intervention period was from January 2019 to March 2020. RESULTS: Between January 2016 and March 2020, there were 203 seizure treatment events (160 preintervention and 43 postintervention) in the ICN. Time to treatment of neonatal seizures decreased by 48%, from a baseline of 27 minutes (January 2016 to December 2018) to 14 minutes by March 2020, which reflected significant and sustained improvement. This was associated with improvement in the process metric during the same time periods. Unnecessary seizure rescue process activations were stable postintervention. CONCLUSIONS: Implementation of an innovative seizure rescue process, in conjunction with staff and provider education, expedited antiseizure therapy in the ICN without requiring code resources.

Effectiveness of Pediatric Asthma Pathways in Community Hospitals: A Multisite Quality Improvement Study.

Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve pediatric asthma care, but mainly in studies at tertiary children's hospitals. Our global aim was to enhance the quality of asthma care across multiple measures by implementing pathways in community hospitals. METHODS: This quality improvement study included children ages 2-17 years with a primary diagnosis of asthma. Data were collected before and after pathway implementation (total 28 mo). Pathway implementation involved local champions, educational meetings, audit/feedback, and electronic health record integration. Emergency department (ED) measures included severity assessment at triage, timely systemic corticosteroid administration (within 60 mins), chest radiograph (CXR) utilization, hospital admission, and length of stay (LOS). Inpatient measures included screening for secondhand tobacco and referral to cessation resources, early administration of bronchodilator via metered-dose inhaler, antibiotic prescription, LOS, and 7-day readmission/ED revisit. Analyses were done using statistical process control. RESULTS: We analyzed 881 ED visits and 138 hospitalizations from 2 community hospitals. Pathways were associated with increases in the proportion of children with timely systemic corticosteroid administration (Site 1: 32%-57%, Site 2: 62%-75%) and screening for secondhand tobacco (Site 1: 82%-100%, Site 2: 54%-89%); and decreases in CXR utilization (Site 1: 44%-29%), ED LOS (Site 1: 230-197 mins), and antibiotic prescription (Site 2: 23%-3%). There were no significant changes in other outcomes. CONCLUSIONS: Pathways improved pediatric asthma care quality in the ED and inpatient settings of community hospitals.

Best practices in implementing inpatient pediatric asthma pathways: a qualitative study.

Objective: Clinical pathways (operational versions of practice guidelines) can improve guideline adherence and quality of care for children hospitalized with asthma. However, there is limited guidance on how to implement pathways successfully. Our objective was to identify potential best practices in pathway implementation.Methods: In a previous observational study, we identified higher and lower performing children's hospitals based on hospital-level changes in asthma patient length of stay after implementation of a pathway. In this qualitative study, we conducted semi-structured interviews with a purposive sample of healthcare providers involved in pathway implementation at these hospitals. We used constant comparative methods to develop a conceptual model of potential best practices in implementation.Results: Healthcare providers (n = 24) from 6 higher performing and 2 lower performing hospitals were interviewed about pathway implementation. We identified several practices that addressed barriers and promoted successful pathway implementation: (1) utilizing quality improvement (QI) methodology and a data-driven approach helped overcome inertia of current practice; (2) getting teams to commit to shared goals around asthma care helped overcome disagreements in the implementation process; (3) integrating pathways into the electronic medical record decreased some burdens of implementation; (4) leveraging multidisciplinary teams by developing protocols for nurses and/or respiratory therapists to titrate medications reduced variability in provider practice; and (5) engaging hospital leaders with pathway implementation teams helped secure crucial resources.Conclusions: We identified several potential best practices to support pathway implementation. Hospitals implementing pathways should consider applying these strategies to better ensure success in improving quality of asthma care for children.

Nursing Surveillance for Deterioration in Pediatric Patients: An Integrative Review.

PROBLEM: Adverse events occur in up to 19% of pediatric hospitalized patients, often associated with delays in recognition or treatment. While early detection is recognized as a primary determinant of recovery from deterioration, most research has focused on profiling patient risk and testing interventions, and less on factors that impact surveillance efficacy. This integrative review explored actions and factors that influence the quality of pediatric nursing surveillance. ELIGIBILITY CRITERIA: Original research on nursing surveillance, escalation of care, or cardiopulmonary deterioration in hospitalized pediatric patients in non-critical environments, published in English in peer reviewed journals. SAMPLE: Twenty-four studies from a literature search within the databases of CINAHL, PubMed, and Web of Science were evaluated and synthesized using a socio-technical systems theory framework. Study quality was assessed using The Mixed Methods Appraisal Tool. RESULTS: Assessment, documentation, decision-making, intervening and communicating were identified as activities associated with surveillance of deterioration. Factors that influenced nurses' detection of deterioration were patient acuity, nurse education, experience, expertise and confidence, staffing, standardized assessment and communication tools, availability of emergency services, team composition and opportunities for multidisciplinary care planning. CONCLUSIONS: Research provides insight into some aspects of nursing surveillance but does not adequately explore factors that affect clinical data interpretation and synthesis, and role integration between nurse and parents, and nurse and other clinicians on surveillance of clinical stability. IMPLICATIONS: Research is needed to enhance understanding of the contextual factors that impact nursing surveillance to inform intervention design to support nurses' timely recognition and mitigation of clinical deterioration.

Keeping Time: Implementing Appointment-based Family-centered Rounds.

BACKGROUND: Family-centered rounds (FCRs) provide many benefits over traditional rounds, including higher patient satisfaction, and shared mental models among staff. These benefits can only be achieved when key members of the care team are present and engaged. We aimed to improve patient engagement and satisfaction with our existing bedside rounds by designing a new FCR process. METHODS: We conducted a needs assessment and formed a multidisciplinary FCR committee that identified appointment-based family-centered rounds (aFCRs) as a primary intervention. We designed, implemented, and iteratively refined an aFCR process. We tracked process metrics (rounds attendance by key participants), a balancing metric (time per patient), and outcome metrics (patient satisfaction domains) during the intervention and follow-up periods. RESULTS: After implementing aFCR, 65% of patients reported positive experience with rounds and communication. Rounds duration per patient was similar (9 versus 9.4 min). Nurse, subspecialist, and interpreter attendance on rounds was 72%, 60%, and 90%, respectively. We employed a Rounding Coordinator to complete the scheduling and communication required for successful aFCR. DISCUSSION: We successfully improved our rounding processes through the introduction of aFCR with the addition of a rounding coordinator. Our experience demonstrates one method to increase multidisciplinary team member attendance on rounds and patient satisfaction with physician communication in the inpatient setting.

The effect of early child care attendance on childhood asthma and wheezing: A meta-analysis.

OBJECTIVE: Research evidence offers mixed results regarding the relationship between early child care attendance and childhood asthma and wheezing. A meta-analysis was conducted to synthesize the current research evidence of the association between early child care attendance and the risk of childhood asthma and wheezing. METHOD: Peer reviewed studies published from 1964-January 2017 were identified in MEDLINE, CINAL, and EMBASE using MeSH headings relevant to child care and asthma. Two investigators independently reviewed the selected articles from this search. All relevant articles that met our inclusion criteria were selected for further analysis. Data were extracted from studies that had sufficient data to analyze the odds of asthma or wheezing among children who attended child care. RESULTS: The meta-analysis of 32 studies found that (1) early child care attendance is protective against asthma in children 3-5 years of age but not for children with asthma 6 years of age or older. (2) Early child care attendance increases the risk of wheezing among children 2 years of age or younger, but not the risk of wheezing for children over 2 years of age. CONCLUSIONS: This meta-analysis shows that early child care attendance is not significantly associated with the risk of asthma or wheeze in children 6 years of age or older.

Effectiveness of Pediatric Asthma Pathways for Hospitalized Children: A Multicenter, National Analysis.

OBJECTIVE: To determine if clinical pathways affect care and outcomes for children hospitalized with asthma using a multicenter study. STUDY DESIGN: This was a retrospective, multicenter cohort study using an administrative database, the Pediatric Health Information System. We evaluated the impact of inpatient pediatric asthma pathways on children age 2-17 years admitted for asthma from 2006 to 2015 in 42 children's hospitals. Date of pathway implementation for each hospital was collected via survey. Using generalized estimating equations with an interrupted time series approach (to account for secular trends), we determined the association of pathway implementation with length of stay (LOS), 30-day readmission, chest radiograph utilization, ipratropium administration >24 hours, and administration of bronchodilators, systemic steroids, and antibiotics. All analyses were risk-adjusted for patient and hospital characteristics. RESULTS: Clinical pathway implementation was associated with an 8.8% decrease in LOS (95% CI 6.7%-10.9%), 3.1% decrease in hospital costs (95% CI 1.9%-4.3%), increased odds of bronchodilator administration (OR 1.53[1.21-1.95]) and decreased odds of antibiotic administration (OR 0.93[0.87-0.99]) (n = 189 331). We found no associations between pathway implementation and systemic steroid administration, ipratropium administration for >24 hours, chest radiograph utilization, or 30-day readmission. CONCLUSIONS: Clinical pathways can decrease LOS, costs, and unnecessary antibiotic use without increasing rates of readmissions, leading to higher value care.

Rising utilization of inpatient pediatric asthma pathways.

INTRODUCTION: Clinical pathways are detailed care plans that operationalize evidence-based guidelines into an accessible format for health providers. Their goal is to link evidence to practice to optimize patient outcomes and delivery efficiency. It is unknown to what extent inpatient pediatric asthma pathways are being utilized nationally. OBJECTIVES: (1) Describe inpatient pediatric asthma pathway design and implementation across a large hospital network. (2) Compare characteristics of hospitals with and without pathways. METHODS: We conducted a descriptive, cross-sectional, survey study of hospitals in the Pediatric Research in Inpatient Settings Network (75% children's hospitals, 25% community hospitals). Our survey determined if each hospital used a pathway and pathway characteristics (e.g. pathway elements, implementation methods). Hospitals with and without pathways were compared using Chi-square tests (categorical variables) and Student's t-tests (continuous variables). RESULTS: Surveys were distributed to 3-5 potential participants from each hospital and 302 (74%) participants responded, representing 86% (106/123) of surveyed hospitals. From 2005-2015, the proportion of hospitals utilizing inpatient asthma pathways increased from 27% to 86%. We found variation in pathway elements, implementation strategies, electronic medical record integration, and compliance monitoring across hospitals. Hospitals with pathways had larger inpatient pediatric programs [mean 12.1 versus 6.1 full-time equivalents, p = 0.04] and were more commonly free-standing children's hospitals (52% versus 23%, p = 0.05). CONCLUSIONS: From 2005-2015, there was a dramatic rise in implementation of inpatient pediatric asthma pathways. We found variation in many aspects of pathway design and implementation. Future studies should determine optimal implementation strategies to better support hospital-level efforts in improving pediatric asthma care and outcomes.

Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions.

OBJECTIVE: Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED. METHODS: A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared. RESULTS: A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45 min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1 h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received > 1 bronchodilator dose within 1 h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76). CONCLUSION: A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.

Emergency department crowding and younger age are associated with delayed corticosteroid administration to children with acute asthma.

OBJECTIVE: This study aimed to identify factors associated with delayed or omission of indicated steroids for children seen in the emergency department (ED) for moderate-to-severe asthma exacerbation. METHODS: This was a retrospective study of pediatric (age ≤ 21 years) patients treated in a general academic ED from January 2006 to September 2011 with a primary diagnosis of asthma (International Classification of Diseases, Ninth Revision code 493.xx) and moderate-to-severe exacerbations. A moderate-to-severe exacerbation was defined as requiring 2 or more (or continuous) bronchodilators. We determined the proportion of visits in which steroids were inappropriately omitted or delayed (>1 hour from arrival). Multivariable logistic regression models were used to identify patient, physician, and system factors associated with delayed or omitted steroids. RESULTS: Of 1333 pediatric asthma ED visits, 817 were for moderate-to-severe exacerbation; 645 (79%) received steroids. Patients younger than 6 years (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.19-4.24), requiring more bronchodilators (OR, 2.82; 95% CI, 2.10-3.79), initially hypoxic (OR, 2.78; 95% CI, 1.33-5.83), or tachypneic (OR, 1.52; 95% CI, 1.05-2.20) were more likely to receive steroids. Median time to steroid administration was 108 minutes (interquartile range, 65-164 minutes). Steroid administration was delayed in 502 visits (78%). Patients with hypoxia (OR, 1.91; 95% CI, 1.11-3.27) or tachypnea (OR, 1.82; 95% CI, 1.17-2.84) were more likely to receive steroids 1 hour or less of arrival, whereas children younger than 2 years (OR, 0.16; 95% CI, 0.07-0.35) and those arriving during periods of higher ED volume (OR, 0.79; 95% CI, 0.67-0.94) were less likely to receive timely steroids. CONCLUSIONS: In this ED, steroids were underprescribed and frequently delayed for pediatric ED patients with moderate-to-severe asthma exacerbation. Greater ED volume and younger age are associated with delays. Interventions are needed to expedite steroid administration, improving adherence to National Institutes of Health asthma guidelines.

Boarding admitted children in the emergency department impacts inpatient outcomes.

OBJECTIVE: This study aimed to assess the relationship between boarding of admitted children in the emergency department (ED) and cost, inpatient length of stay (LOS), mortality, and readmission. METHODS: This was a retrospective study of 1,792 pediatric inpatients admitted through the ED and discharged from the hospital between February 20, 2007 and June 30, 2008 at a major teaching hospital with an annual ED volume of 40,000 adult and pediatric patients.The main predictor variable was boarding time (time from admission decision to departure for an inpatient bed, in hours). Covariates were patient age, payer group, times of ED and inpatient bed arrival, ED triage acuity, type of inpatient service, intensive care unit admission, surgery, and severity of inpatient illness. The main outcome measures, cost (dollars) and inpatient LOS (hours), were log-transformed and analyzed using linear regressions. Secondary outcomes, mortality and readmission to the hospital within 72 hours of discharge, were analyzed using logistic regression. RESULTS: Mean ED LOS for admitted patients was 9.0 hours. Mean boarding time was 5.1 hours. Mean cost and inpatient LOS were $9893 and 147 hours, respectively. In general, boarding time was associated with cost (P < 0.001) and inpatient LOS (P = 0.01) but not with mortality or readmission. Longer boarding times were associated with greater inpatient LOS especially among patients triaged as low acuity (P = 0.008). In addition, longer boarding times were associated with greater probability of being readmitted among patients on surgical services (P = 0.01). CONCLUSIONS: Among low-acuity and surgical patients, longer boarding times were associated with longer inpatient LOS and more readmissions, respectively.

Pediatric hospitalist research productivity: predictors of success at presenting abstracts and publishing peer-reviewed manuscripts among pediatric hospitalists.

OBJECTIVE: To identify factors associated with research productivity among pediatric hospitalists. METHODS: We performed a cross-sectional online survey of pediatric hospitalists recruited from the American Academy of Pediatrics Section on Hospital Medicine from May to August 2009. We used abstract presentations at a national meeting (intermediate outcome) and 22 first-author peer-reviewed manuscripts (primary outcome) to measure research productivity. Information was also collected on environmental and physician characteristics. Stepwise logistic regression was performed to identify independent associations with research productivity. RESULTS: Two hundred fifteen pediatric hospitalists completed the survey. The respondents included 82% in an academic environment, 150% fellowship trained, 25% with additional degrees, and 67% with no protected time for research. Fifty-six percent presented an abstract, and 17% had 2 or more publications. After adjusting for potential confounders, pediatric hospitalists were more likely to have presented an abstract if they had fellowship training, an additional degree, were "very interested" or "interested" in performing research, or worked in a free-standing children's hospital or children's hospital within a hospital. Pediatric hospitalists were more likely to have 2 or more publications if they had an additional degree or had presented an abstract. CONCLUSIONS: Among pediatric hospitalists, obtaining an additional degree and presenting an abstract at a national meeting are associated with research productivity. A minority of this group of pediatric hospitalists had fellowship training, degree training, or 2 or more first-author manuscripts published even though the majority are in an academic environment. These results suggest that structured training and a focus on abstract presentations at meetings could be a programmatic solution.

Factors associated with prolonged emergency department length of stay for admitted children.

OBJECTIVE: To estimate the prevalence of and to identify factors associated with prolonged emergency department length-of-stay (ED-LOS) for admitted children. METHODS: Data were from the 2001-2006 National Hospital Ambulatory Medical Care Survey. The primary outcome was prolonged ED-LOS (defined as total ED time >8 hours) among admitted children. Predictor variables included patient-level (eg, demographics including race/ethnicity, triage score, diagnosis, and admission to inpatient bed vs intensive care unit), physician-level (intern/resident vs attending physician), and system-level (eg, region, metropolitan area, ED and hospital type, time and season, and diagnostic and therapeutic procedures) factors. Multivariable logistic regression was performed to identify independent predictors of prolonged ED-LOS. RESULTS: Median ED-LOS for admitted children was 3.7 hours. Thirteen percent of pediatric patients admitted from the ED experienced prolonged ED-LOS. Factors associated with prolonged ED-LOS for admitted children were Hispanic ethnicity (odds ratio [OR], 1.76; 95% confidence interval [95% CI], 1.10-2.81), ED arrival between midnight and 8 a.m. (OR, 2.80; 95% CI, 1.87-4.20), winter season (January-March: OR, 1.81; 95% CI, 1.20-2.74), computed tomography scan or magnetic resonance imaging (OR, 1.65; 95% CI, 1.05-2.58), and intravenous fluids or medications (OR, 1.81; 95% CI, 1.10-2.97). Children requiring ICU admissions (OR, 0.29; 95% CI, 0.11-0.77) or receiving pulse oximetry in the ED (OR, 0.52; 95% CI, 0.34-0.81) had a lower risk of experiencing prolonged ED-LOS. CONCLUSIONS: We found that prolonged ED-LOS occurs frequently for admitted pediatric patients and is associated with Hispanic ethnicity, presentation during winter season, and early morning arrival. Potential strategies to reduce ED-LOS include improved availability of interpreter services and enhanced staffing and additional inpatient bed availability during winter season and overnight hours.

Pediatric emergency departments are more likely than general emergency departments to treat asthma exacerbation with systemic corticosteroids.

OBJECTIVE: To determine whether systemic corticosteroids are under-prescribed (as measured by current NIH treatment guidelines) for children in the United States seen in the emergency department (ED) for acute asthma, and to identify factors associated with prescribing systemic corticosteroids. METHODS: We used data from the 2001-2007 National Hospital Ambulatory Medical Care Survey. The study population was children ≤ 18 years old in the ED with a primary diagnosis of asthma (ICD-9-CM code 493.xx) who received bronchodilator(s). The primary outcome was receipt of a systemic corticosteroid in the ED. Independent variables included patient-level (e.g., demographics, insurance, fever, admission), physician-level (provider type, ancillary medications and tests ordered), and system-level factors (e.g., ED type, geographic location, time of day, season, year). We used multivariable logistic regression techniques to identify factors associated with systemic corticosteroid treatment. RESULTS: Systemic corticosteroids were prescribed at only 63% of pediatric acute asthma visits to EDs. Over the study period, there was a trend toward increasing systemic corticosteroid use (p for trend = .05). After adjusting for potential confounders, patients were more likely to receive systemic corticosteroids when treated in pediatric EDs than in general EDs (OR = 2.45; 95% CI: 1.26-4.77). CONCLUSION: Systemic corticosteroids are under-prescribed for children who present to EDs with acute asthma exacerbations. Pediatric EDs are more likely than general EDs to treat asthma exacerbations with systemic corticosteroids. Differences in the process of care in pediatric ED settings (compared to general EDs) may increase the likelihood of adherence to NIH treatment guidelines.

Research needs of pediatric hospitalists.

OBJECTIVE: To assess the current state of research productivity, goals, obstacles, and needs of pediatric hospitalists. METHODS: The American Academy of Pediatrics Section on Hospital Medicine performed a cross-sectional online survey of pediatric hospitalists. Questions assessed demographics, research productivity, system-level factors, research interests, goals and obstacles, and the perceived need for research training and support. RESULTS: Two hundred twenty pediatric hospitalists in the United States completed the survey. Of these, 56% had presented at a national meeting, 24% were first authors of an article in a peer-reviewed journal, 8% had more than publications, and 12% had secured external grant support. While 90% of respondents had spent 10% or less time in research, 64% had an academic appointment at the assistant professor level or above. Nearly 40% felt that their institution expected them to do research, and 56% were interested and another 27% were very interested in conducting research. The main research interest was quality improvement (QI) evaluation. Common obstacles to research were lack of time, mentorship, and resources. CONCLUSIONS: Pediatric hospitalists want to conduct research to improve the quality of inpatient care but face significant obstacles including lack of dedicated time for research and mentorship. Coordinated efforts to improve access to academic resources are important for career development and academic growth of the field. National organizations and hospital programs interested in improving the quality of care for hospitalized children can provide support to meet the field's professional needs for research.

Standardized admission order set improves perceived quality of pediatric inpatient care.

BACKGROUND: Few studies exist on the ability of standardized preprinted order forms to improve patient care. OBJECTIVE: To examine resident-perceived effects of introducing a pediatric admission order set (PAOS) on the quality of inpatient care. DESIGN: Cross-sectional study. SETTING: University of California, Los Angeles (UCLA) Children's Hospital, a nonprofit, tertiary-care teaching hospital and major referral center with approximately 3,000 admissions per year. PARTICIPANTS: A total of 97 pediatric residents (PL-1, n=34; PL-2, n=33; and PL-3, n=30) who did the vast majority of the inpatient admissions. MEASUREMENTS: Residents were asked to rate the PAOS overall and with respect to 9 specific dimensions using a 5-point Likert scale. RESULTS: Overall, 89% of respondents approved of the PAOS, 58% reported using it >or= 90% of the time, and all said that they would recommend it to their colleagues. Eighty-four percent thought that it improved inpatient care, and 75% thought that medical errors were reduced. Eighty-eight percent reported that the PAOS saved time; 93% said it was convenient; and most reported less need for clarification with secretaries (81%) and nurses (82%). In multivariate regression analyses, the only predictor of overall rating was whether the PAOS improved inpatient care (P=0.04). Improved patient care, meanwhile, was predicted by whether the PAOS was comprehensive (P=0.01), reduced medical errors (P=0.01), and required less clarification with nurses (P=0.01). CONCLUSIONS: A standardized admission order set is a simple, low-cost intervention that residents believe may benefit patients by reducing medical errors and expediting high-quality care.

Jaundice in a neonate with congenital diaphragmatic hernia.

A six-week-old boy presented to the emergency department with worsening jaundice. His medical history included congenital diaphragmatic hernia repaired shortly after birth. Significant jaundice, unresponsive to phototherapy, was noted on the eighth day of life. His total bilirubin level decreased when he was advanced to full oral feeds. However, on the 23rd day of life, the patient's conjugated bilirubin level had tripled. This was attributed to total parenteral nutrition, and the patient was discharged home. Over the next month, his jaundice worsened. The patient was readmitted and ultimately diagnosed with cytomegalovirus (CMV) hepatitis. After treatment with ganciclovir, his hepatitis completely resolved. CMV infection is a common cause of neonatal hepatitis and congenital malformation. Prolonged neonatal jaundice that does not improve with transitioning from total parenteral nutrition to oral feeds warrants further evaluation. Simple laboratory investigation can avoid unnecessary and potentially harmful medical and surgical interventions. Early treatment of neonatal CMV infection reduces the risk of long-term neurological and hepatic complications.