Perioperative Health Interventions in Children With Chronic Neuromuscular Conditions Undergoing Major Musculoskeletal Surgery: A Scoping Review.

BACKGROUND AND OBJECTIVES: Children with chronic neuromuscular conditions (CCNMC) have many coexisting conditions and often require musculoskeletal surgery for progressive neuromuscular scoliosis or hip dysplasia. Adequate perioperative optimization may decrease adverse perioperative outcomes. The purpose of this scoping review was to allow us to assess associations of perioperative health interventions (POHI) with perioperative outcomes in CCNMC. METHODS: Eligible articles included those published from January 1, 2000 through March 1, 2022 in which the authors evaluated the impact of POHI on perioperative outcomes in CCNMC undergoing major musculoskeletal surgery. Multiple databases, including PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, Web of Science, the Cochrane Library, Google Scholar, and ClinicalTrials.gov, were searched by using controlled vocabulary terms and relevant natural language keywords. Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines were used to perform the review. A risk of bias assessment for included studies was performed by using the Risk of Bias in Non-randomized Studies of Interventions tool. RESULTS: A total of 7013 unique articles were initially identified, of which 6286 (89.6%) were excluded after abstract review. The remaining 727 articles' full texts were then reviewed for eligibility, resulting in the exclusion of 709 (97.5%) articles. Ultimately, 18 articles were retained for final analysis. The authors of these studies reported various impacts of POHI on perioperative outcomes, including postoperative complications, hospital length of stay, and hospitalization costs. Because of the heterogeneity of interventions and outcome measures, meta-analyses with pooled data were not feasible. CONCLUSIONS: The findings reveal various impacts of POHI in CCNMC undergoing major musculoskeletal surgery. Multicenter prospective studies are needed to better address the overall impact of specific interventions on perioperative outcomes in CCNMC.

Characteristics of Pediatric Hospital Medicine Fellowship Program Directors.

BACKGROUND AND OBJECTIVES: Rapid growth in pediatric hospital medicine (PHM) fellowships has occurred, yielding many new program directors (PDs). Characteristics of PDs have potential implications on the field. To describe characteristics (demographic, educational) and scholarly interests of PHM fellowship PDs. METHODS: We developed and distributed a 15-question, cross-sectional national survey to the PHM PDs listserv. Questions were pilot tested. The survey was open for 4 weeks with weekly reminders. Responses were summarized using descriptive statistics. RESULTS: Fifty-six current fellowship leaders (40 PDs, 16 associate PDs [APDs]) responded, including at least 1 from 43 of 59 active PHM fellowship programs (73%). Most respondents identified as female (71%) and ≤50 years old (80%). Four (7%, n = 2 PD, 2 APD) leaders identified as underrepresented in medicine. About half (n = 31, 55.4%) completed a fellowship themselves (APDs > PDs; 87.5% vs 42.5%), and 53.5% (n = 30) had advanced nonmedical degrees (eg, Master of Science, Doctor of Philosophy; APDs > PDs; 62% vs 45%). Most leaders (59%, n = 33) chose multiple domains when asked to select a "primary domain of personal scholarship." Education was the most frequently selected (n = 37), followed by quality improvement (n = 29) and then clinical research (n = 19). CONCLUSIONS: This survey confirms a high percentage of women as PHM fellowship leaders and highlights the need to increase diversity. Less than half of senior PDs completed a fellowship in any specialty. Leaders report interest in multiple domains of scholarship; few focus solely on clinical research.

Physician perceptions of documentation methods in electronic health records.

This study sought to determine physician, specialty and practice factors influencing choice of method for electronic health record (EHR) documentation: direct typing (DT), electronic transcription (ET), human transcription (HT), and scribes. A survey assessing physician documentation practices was developed and distributed online. The primary outcome was the proportion of physicians using each method. Secondary outcomes were provider-rated accuracy, efficiency, and ease of navigation on a 1-5 Likert scale. Means were compared using linear mixed models with Bonferroni adjustment. The 818 respondents were mostly outpatient (46%) adult (79%) physicians, practiced for a mean 15.8 years, and used DT for EHR documentation (72%). Emergency physicians were more likely to use scribes (p < 0.0001). DT was rated less efficient than all other methods (p < 0.0001). ET was rated less accurate than DT (p < 0.001) and HT (p < 0.001). HT was rated less easy to navigate than DT (p = 0.002) and scribe (p < 0.001), and ET less than scribe (p = 0.002). Two hundred and forty-three respondents provided free-text comments that further described opinions. DT was the most commonly used EHR method but rated least efficient. Scribes were rated easy to navigate and efficient but infrequently used outside of emergency settings. Further innovation is needed to design systems responsive to all physician EHR needs.

Socially-Assistive Robots Using Empathy to Reduce Pain and Distress during Peripheral IV Placement in Children.

Objectives: Socially-assistive robots (SAR) have been used to reduce pain and distress in children in medical settings. Patients who perceive empathic treatment have increased satisfaction and improved outcomes. We sought to determine if an empathic SAR could be developed and used to decrease pain and fear associated with peripheral IV placement in children. Methods: We conducted a pilot study of children receiving IV placement. Participating children were randomized to interact with (1) no robot, or a commercially available 3D printed humanoid SAR robot programmed with (2) empathy or (3) distraction conditions. Children and parents completed demographic surveys, and children used an adapted validated questionnaire to rate the robot's empathy on an 8-point Likert scale. Survey scores were compared by the t-test or chi-square test. Pain and fear were measured by self-report using the FACES and FEAR scales, and video tapes were coded using the CHEOPS and FLACC. Scores were compared using repeated measures 2-way ANOVA. This trial is registered with NCT02840942. Results: Thirty-one children with an average age of 9.6 years completed the study. For all measures, mean pain and fear scores were lowest in the empathy group immediately before and after IV placement. Children were more likely to attribute characteristics of empathy to the empathic condition (Likert score 7.24 v. 4.70; p=0.012) and to report that having the empathic vs. distraction robot made the IV hurt less (7.45 vs. 4.88; p=0.026). Conclusions: Children were able to identify SAR designed to display empathic characteristics and reported it helped with IV insertion pain and fear. Mean scores of self-reported or objective pain and fear scales were the lowest in the empathy group and the highest in the distraction condition before and after IV insertion. This result suggests empathy improves SAR functionality when used for painful medical procedures and informs future research into SAR for pain management.

Medical Student Training in Pediatric Hospital Medicine: A National Survey of Pediatric Clerkships.

BACKGROUND AND OBJECTIVES: Medical student electives offer opportunities for career exploration; it is unknown if electives exist for the newest pediatric subspecialty, pediatric hospital medicine (PHM), or how PHM competencies are already addressed in required medical student training. Our objectives for this study were (1) to determine the prevalence of exposure to PHM competencies in medical school and (2) to inform a needs assessment for a PHM elective. METHODS: A 5-item survey was distributed to members of the Council on Medical Student Education in Pediatrics as part of a larger survey in 2018. Descriptive statistics were used to report responses as proportions. Responses to 1 open-ended question were coded and grouped into categories. RESULTS: Of 152 total respondents, 118 (77.6%) answered at least 1 question. Respondents felt that quality improvement was addressed in preclinical years (40.4%), whereas systems-based practice was incorporated into core clerkships (32.1%). Although most indicated that leadership and education should be taught at the subinternship level (29.6% and 25%, respectively), those competencies are not currently integrated into subinternship rotations (7.4% and 4.8%, respectively). Approximately half (n = 58; 49.5% each) reported that their institution offers a PHM elective. Lack of a standardized curriculum (16%) was seen as a barrier, and in free-text responses (n = 33), respondents also noted concerns regarding saturation of inpatient settings and redundancy with required rotations. CONCLUSIONS: How to become a good leader and how to become a good educator were identified as PHM competencies that should be, but are not currently, taught at the fourth-year medical student level. A standardized curriculum and strategies to mitigate redundancy with existing rotations may increase satisfaction of students.

Socially Assistive Robots for Helping Pediatric Distress and Pain: A Review of Current Evidence and Recommendations for Future Research and Practice.

OBJECTIVES: Interacting with socially assistive robots (SAR) has been shown to influence human behaviors and emotions. This study sought to review the literature on SAR intervention for reducing pediatric distress and pain in medical settings. METHODS: Databases (PubMed, Cochrane Library, CINAHL, PsycINFO, ERIC, Web of Science, Engineering Village, Scopus, Google Scholar, IEEE Xplore) were searched from database inception to January 2018 with the aid of a medical librarian. Included studies examined any SAR intervention for reducing pain or improving emotional well-being in children related to physical or psychiatric care, with outcomes assessed by some quantitative measure. Study quality was assessed using the modified Downs and Black checklist (max. score, 28). The review is registered in PROSPERO (CRD42016043018). RESULTS: Eight studies met the eligibility criteria and represented 206 children. Of the 2 studies using Wong-Baker's FACES scale, 1 study claimed to be effective at reducing pain (Cohen d=0.49 to 0.62), while the other appeared effective only when parents and child interacted with SAR together. Distress was evaluated using validated measures in 4 studies, 3 of which showed reduction in distress while one showed no difference. Satisfaction surveys from 4 studies showed that children were interested in using SAR again. Quality scores ranged from 8 to 26. CONCLUSIONS: There is limited evidence suggesting that SAR interventions may reduce distress and no clear evidence showing reduction in pain for children in medical settings. Engineers are conducting interventions using SAR in pediatric populations. Health care providers should be engaged in technology research related to children to facilitate testing and improve the effectiveness of these systems.

Medical Student Participation in Patient- and Family-Centered Rounding: A National Survey of Pediatric Clerkships.

OBJECTIVE: Pediatrics rotations may be medical students' only experience with patient- and family-centered rounding (PFCR). It is unclear how students participate in or are prepared for PFCR. We surveyed national pediatrics clerkships to determine the prevalence of PFCR and the proportion providing orientation in order to inform a needs assessment for PFCR orientation. METHODS: A 5-item peer-reviewed survey was distributed to the Council on Medical Student Education in Pediatrics (COMSEP) membership as part of a larger survey in 2017. Institutional differences among programs performing PFCR were compared using chi-square and t-tests. Responses to 1 open-ended question were coded and grouped into broad categories using content analysis. RESULTS: The full COMSEP survey received answers from 190 participants representing 103 medical schools. Our questions received 174 responses representing 94 schools (98 training sites) and had an 85% (83/98) prevalence of student PFCR participation. Although most (n = 108; 85%) reported that their students received PFCR orientation, half (n = 62; 49%) considered orientation "informal," and only 2 reported using published curricula. After didactics, the most common orientation materials were handouts (n = 33; 26%), videos (n = 13; 10%), and role play (n = 7; 6%). Orientation was most commonly initiated at the start of clerkship (n = 62; 49%) by clerkship administration (n = 38; 30%), but 20% (n = 26) reported resident-led orientation. Qualitative responses (n = 98) were coded and organized into 4 themes; the greatest perceived challenges for medical students on PFCR were communication and anxiety. CONCLUSIONS: Although most students participate in and receive orientation to PFCR, there is wide variability in the content, timing, and administration of orientation. A nationally disseminated, evidence-based orientation curriculum may reduce educational variability and better prepare students for PFCR.

Changing Trends in Brain Imaging Technique for Pediatric Patients with Ventriculoperitoneal Shunts.

BACKGROUND: Children with ventriculoperitoneal shunts (VPS) undergoing brain computed tomography (CT) for shunt malfunction evaluation are at risk for later malignancy due to radiation exposure. We aimed to determine if and how hospitals have adopted radiation-avoiding magnetic resonance imaging (MRI) techniques. METHODS: We performed a secondary analysis of the Pediatric Health Information System (PHIS) database. Children with VPS presenting to acute wards at 31 PHIS hospitals between January 1, 2007 and January 2, 2015 and receiving noncontrast neuroimaging on day of service 0/1 were included. Outcome measures were (1) incidence of MRI over time and (2) comparison of demographic characteristics between hospitals with MRI representing higher versus lower proportions (>15% or <15%) of total brain imaging. RESULTS: MRIs increased by 18.1% from 2007 to 2015. Hospitals were assigned to high-use (n = 12) or minimal-use (n = 19) MRI groups based on year 2014/2015 MRI percentages. The only identified difference was an older mean age in the high-use group (8.1 vs. 7.5 years; p = 0.03). CONCLUSIONS: MRI is increasingly used to evaluate patients with VPS. Hospitals with more MRI use had older patients and no increase in cost or length of stay. Initiating local quality improvement projects may help identify barriers to MRI uptake and increase use.

Risk factors for overnight respiratory events following sedation for magnetic resonance imaging in children with sleep apnea.

PURPOSE: Children with sleep apnea may be at increased risk for overnight respiratory events (ORE) following anesthesia. We sought to identify ORE risk factors in sleep apnea patients sedated for magnetic resonance imaging (MRI). METHODS: One thousand four hundred seven hospitalizations for children with sleep apnea (by ICD-9 code) occurred at our institution from 5/1/2011 to 2/1/2015. One hundred twenty-seven (9 %) encounters were solely for post-MRI observation representing 96 unique patients. The first post-MRI admission for each patient underwent chart review. ORE was defined as sustained oxygen saturation <90 % with need for increased oxygen or adjustment of respiratory support after release from recovery. Characteristics of patients with and without ORE were compared by chi-squared analysis or independent samples t test. Logistic regression identified associations with ORE. RESULTS: Ten out of 96 (10.4 %) patients had ORE. The average time following sedation to ORE was 10.25 h. ORE patients were hospitalized longer (median 2 vs. 1 day, p < 0.001). Overall, patients were 55 % male, 60 % Hispanic, with median age of 5 years [IQR 2-10] and median body mass index (BMI) of 17.9 [IQR 15.2-24]. On logistic regression, apnea-hypopnea index (AHI; OR 1.007 [95 % CI 1.002-1.011]), anesthesia complication (OR 1.13 [95 % CI 1.01-1.28]), and home non-invasive positive pressure ventilation (NIV; OR 6.08 [95 % CI 1.57-26.17]) were associated with ORE. CONCLUSION: Ninety percent of children with sleep apnea admitted for overnight observation following sedated MRI did not have an ORE. AHI, anesthesia complications, and NIV use may help target higher-risk patients and avoid unnecessary hospitalizations.

Screening for maternal postpartum depression during infant hospitalizations.

BACKGROUND: Postpartum depression is common and adversely affects children of afflicted mothers; postpartum depression recognition and treatment may improve outcomes. Hospitalization represents a potential health encounter for expanding screening and intervention. OBJECTIVE: We aimed to assess for postpartum depression at infant hospitalization and examine postpartum depression risk factors in this population. DESIGN, SETTING, AND PARTICIPANTS: We conducted a prospective observational study of 310 English- or Spanish-speaking women with an infant aged 2 weeks to 1 year admitted to a pediatric hospitalist service at a large urban freestanding children's hospital. MEASUREMENTS: Mothers completed demographic questionnaires, a maternal-infant bonding scale, and the Edinburgh Postpartum Depression Scale (EPDS). Mothers with an EPDS score of 10 or higher (positive screen) received counseling and mental health referrals. Postenrollment calls followed trends in EPDS score and resource utilization. Multivariate logistic regression assessed relationships among risk factors and positive screens. RESULTS: Eighty-seven mothers (28%) were EPDS+. Only 14.6% reported appropriate prior depression screening. Maternal factors associated with EPDS+ were poor social support (4.40, interquartile range [IQR] = 2.27-8.53) and history of psychiatric diagnoses (5.02, IQR = 2.49-10.15). Having an infant with neurodevelopmental comorbidities was associated with EPDS+ screens (2.78, IQR = 1.03-7.52). Of 21 initially EPDS+ mothers reached by phone, 8 (38%) utilized their doctor or referral resource, resulting in lower EPDS scores (F(1,19) = 5.743, P < 0.05) compared to those not seeking help. CONCLUSION: Postpartum depression screening during infant hospitalizations captures women previously unscreened. Low social support, past psychiatric diagnoses, or having infants with neurodevelopmental problems may increase postpartum depression risk. Journal of Hospital Medicine 2015;11:840-846. © 2015 Society of Hospital Medicine.