Factors Associated With Improved Pediatric Resuscitative Care in General Emergency Departments.

OBJECTIVES: To describe the quality of pediatric resuscitative care in general emergency departments (GEDs) and to determine hospital-level factors associated with higher quality. METHODS: Prospective observational study of resuscitative care provided to 3 in situ simulated patients (infant seizure, infant sepsis, and child cardiac arrest) by interprofessional GED teams. A composite quality score (CQS) was measured and the association of this score with modifiable and nonmodifiable hospital-level factors was explored. RESULTS: A median CQS of 62.8 of 100 (interquartile range 50.5-71.1) was noted for 287 resuscitation teams from 175 emergency departments. In the unadjusted analyses, a higher score was associated with the modifiable factor of an affiliation with a pediatric academic medical center (PAMC) and the nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. In the adjusted analyses, a higher CQS was associated with modifiable factors of an affiliation with a PAMC and the designation of both a nurse and physician pediatric emergency care coordinator, and nonmodifiable factors of higher pediatric volume and location in the Northeast and Midwest. A weak correlation was noted between quality and pediatric readiness scores. CONCLUSIONS: A low quality of pediatric resuscitative care, measured using simulation, was noted across a cohort of GEDs. Hospital factors associated with higher quality included: an affiliation with a PAMC, designation of a pediatric emergency care coordinator, higher pediatric volume, and geographic location. A weak correlation was noted between quality and pediatric readiness scores.

Leukocyte Heterogeneity in Pancreatic Ductal Adenocarcinoma: Phenotypic and Spatial Features Associated with Clinical Outcome.

Immunotherapies targeting aspects of T cell functionality are efficacious in many solid tumors, but pancreatic ductal adenocarcinoma (PDAC) remains refractory to these treatments. Deeper understanding of the PDAC immune ecosystem is needed to identify additional therapeutic targets and predictive biomarkers for therapeutic response and resistance monitoring. To address these needs, we quantitatively evaluated leukocyte contexture in 135 human PDACs at single-cell resolution by profiling density and spatial distribution of myeloid and lymphoid cells within histopathologically defined regions of surgical resections from treatment-naive and presurgically (neoadjuvant)-treated patients and biopsy specimens from metastatic PDAC. Resultant data establish an immune atlas of PDAC heterogeneity, identify leukocyte features correlating with clinical outcomes, and, through an in silico study, provide guidance for use of PDAC tissue microarrays to optimally measure intratumoral immune heterogeneity. Atlas data have direct applicability as a reference for evaluating immune responses to investigational neoadjuvant PDAC therapeutics where pretherapy baseline specimens are not available. SIGNIFICANCE: We provide a phenotypic and spatial immune atlas of human PDAC identifying leukocyte composition at steady state and following standard neoadjuvant therapies. These data have broad utility as a resource that can inform on leukocyte responses to emerging therapies where baseline tissues were not acquired.This article is highlighted in the In This Issue feature, p. 1861.

Medication errors in a pediatric anesthesia setting: Incidence, etiologies, and error reduction strategies.

STUDY OBJECTIVE: The objective of the study was to: a) characterize the frequency, type, and outcome of anesthetic medication errors spanning an 8.5-year period, b) describe the targeted error reduction strategies and c) measure the effects, if any, of a focused, continuous, multifaceted Medication Safety Program. DESIGN: Retrospective analysis. SETTING: All anesthetizing locations (57). PATIENTS: All anesthesia patients at all Boston Children's Hospital anesthetizing locations from January 2008 to June 2016 were included. INTERVENTIONS: Medication libraries, zero-tolerance philosophy, independent verification, trainee education, standardized dosing; retrospective study. MEASUREMENTS: Number and type of medication errors. MAIN RESULTS: 105 medication errors were identified among the 287,908 cases evaluated during the study period. Incorrect dose (55%) and incorrect medication (28%) were the most frequently observed errors. Beginning within 3 years of the implementation of the 2009 Medication Safety Program, the incidence declined to an average of 3.0 per 10,000 cases in the years from 2010 to 2016 (57% reduction) and declined to an average of only 2.2 per 10,000 cases since 2012 (69% reduction). Logistic regression indicated a 13% reduction per year in the odds of a medication error over the time period (odds ratio = 0.87, 95% CI: 0.79-0.95, P = 0.004). CONCLUSIONS: Although medication errors persisted, there was a statistically significant reduction in errors during the study period. Formalized Medication Safety Programs should be adopted by other departments and institutions; these Programs could help prevent medication errors and decrease their overall incidence.