Standardizing neonatal hypoxic ischemic encephalopathy evaluation and documentation practices.

BACKGROUND: Infants at risk for hypoxic ischemic encephalopathy (HIE) require a time sensitive evaluation and decision-making regarding treatment with therapeutic hypothermia (TH). Prior to this project, there was no standardized approach to evaluating these infants locally. METHODS: Included infants were "at risk for HIE," defined as meeting the "patient characteristics" and "biochemical criteria" per the institutional HIE pathway. Our primary outcome was documentation of an HIE therapeutic hypothermia evaluation (HIETHE) within the first six hours of life which included: (1) recognition of at-risk status, (2) an encephalopathy exam, and (3) a decision regarding TH. Plan-Do-Study-Act cycles included novel clinical decision support. RESULTS: From October 2020 to May 2023, among infants at-risk for HIE, the average percentage with an HIETHE documented improved from 47% to 82%. CONCLUSIONS: We standardized the approach to infants at risk for HIE and improved the presence of a complete and timely evaluation regarding TH eligibility.

Between-hospital variation in clinical decision support availability for common inpatient pediatric conditions: Results of a national Pediatric Research in Inpatient Settings (PRIS) Network survey.

Implementing pediatric-focused clinical decision support (CDS) into hospital electronic health records can lead to improvements in patient care and accelerate quality improvement and research initiatives. However, its design, development, and implementation can be a time-consuming and costly endeavor that may not be feasible for all hospital settings. In this cross-sectional study, we surveyed Pediatric Research in Inpatient Settings (PRIS) Network hospitals about the availability of CDS tools to gain an understanding of the functionality available across 8 common inpatient pediatric diagnoses. Among the conditions, asthma had the most extensive CDS availability, while mood disorders had the least. Overall, freestanding children's hospitals had the greatest breadth in CDS coverage across conditions and depth in CDS types within conditions. Future initiatives should examine the relationship between CDS availability and clinical outcomes as well as its relationship with hospitals' performance executing multicenter informatics projects, quality improvement collaboratives, and implementation science strategies.

The Electronic Health Record as a Quality Improvement Tool: Exceptional Potential with Special Considerations.

The electronic health record (EHR) offers an exciting opportunity for quality improvement efforts. An understanding of the nuances of a site's EHR landscape including the best practices in clinical decision support design, basics of data capture, and acknowledgment of the potential unintended consequences of technology change is essential to ensuring effective usage of this powerful tool.

Improving Compliance with a Rounding Checklist through Low- and High-technology Interventions: A Quality Improvement Initiative.

INTRODUCTION: Checklists aid in ensuring consistency and completeness in medical care delivery. However, using an improvement and safety checklist during rounds was variable in our neonatology intensive care unit (NICU), and completion was not tracked sustainably. This quality improvement (QI) initiative's primary aim was to increase compliance with checklist completion from 31% to >75% within 1 year. METHODS: A multidisciplinary QI team identified barriers to checklist completion and implemented a human factors-focused low-technology intervention (redesign of a hard-copy checklist) and later a high-technology clinical decision support tool within the electronic health record. The primary outcome measure was percent compliance with the use of the checklist. Process metrics included the duration of checklist completion. Balancing measures included staff perceptions of work burden and question relevance. RESULTS: Major barriers to checklist utilization were inability to remember, rounding interruptions, and perceived lack of question relevance to patients. Average biweekly checklist compliance improved from 31% before interventions to 80% after interventions. Average checklist completion time decreased from 46 to 11 seconds. Follow-up surveys demonstrated more respondents found questions "completely relevant" (34% pre versus 43% post) but perceived increased work burden (26% pre versus 31% post). CONCLUSIONS: Using QI methodology, human factors-based interventions, and a novel clinical decision support tool, we significantly improved efficiency and checklist compliance and created an automated, sustainable method for monitoring completion and responses. This foundational project provides an infrastructure broadly applicable to QI work in other healthcare settings.

Pediatric Emergency Medicine Simulation Curriculum: Vitamin K Deficiency in the Newborn.

Introduction: The American Academy of Pediatrics recommends vitamin K prophylaxis at birth for all newborns to prevent vitamin K deficiency bleeding (VKDB). Despite a lack of evidence for serious harms, barriers to prophylaxis, including parental refusal, are rising, as are cases of VKDB. Methods: This simulation involved an infant presenting to the emergency department who decompensated due to a cerebral hemorrhage caused by VKDB and was treated by pediatric and emergency providers. The case was incorporated into the fellow and division monthly curricula, and participants completed postsimulation surveys. The patient required a secure airway, seizure management, vitamin K, and a fresh frozen plasma infusion upon suspicion of the diagnosis, plus a coordinated transfer to definitive care. The case included a description of the simulated case, learning objectives, instructor notes, an example of the ideal flow of the scenario, anticipated management mistakes, and educational materials. Results: The simulations were carried out with 48 total participants, including 40 fellows and eight attendings, from five different training institutions over 1 year. In surveys, respondents gave overall positive feedback. Ninety-four percent of participants gave the highest score on a Likert scale indicating that the simulation was relevant, and over 80% gave the highest score indicating that the experience helped them with medical management. Discussion: This simulation trained physicians how to recognize and treat a distressed infant with VKDB. The case was perceived to be an effective learning tool for both fellow and attending physicians.

Extreme thrombocytosis is associated with critical illness and young age, but not increased thrombotic risk, in hospitalized pediatric patients.

BACKGROUND: Extreme thrombocytosis (EXT, platelet count > 1000 × 103 /µL) is an uncommon but potentially clinically significant finding. Primary EXT in the setting of myeloproliferative disorders is linked to thrombotic and/or bleeding complications more frequently than secondary EXT, which typically occurs in reaction to infection, inflammation, or iron deficiency. However, comorbidities have been reported in adults with secondary EXT. Clinical implications of EXT in children are not well defined, as prior studies targeted small and/or specialized pediatric populations. OBJECTIVES: Our objectives were to determine etiologies and sequelae of EXT in a hospitalized general pediatric patient population. PATIENTS AND METHODS: We retrospectively analyzed EXT cases from a single-center pediatric cohort of ~80 000 patients over 8 years. RESULTS: Virtually all cases (99.8%) were secondary in nature, and most were multifactorial. Many cases of EXT occurred in children under 2 years old (47%) and/or during critical illness (55%). No thrombotic or bleeding events directly resulted from EXT, confirming a paucity of clinical complications associated with EXT in pediatric patients. There were indications that neonatal hematopoiesis and individual genetic variation influenced some cases, in addition to certain diagnoses (eg, sickle cell anemia) and clinical contexts (eg, asplenia). CONCLUSION: Our findings confirm that thrombotic events related to EXT are rare in pediatric patients, which can inform the use of empiric anti-platelet therapy.

Infection dynamics, dispersal, and adaptation: understanding the lack of recovery in a remnant frog population following a disease outbreak.

Emerging infectious diseases can cause dramatic declines in wildlife populations. Sometimes, these declines are followed by recovery, but many populations do not recover. Studying differential recovery patterns may yield important information for managing disease-afflicted populations and facilitating population recoveries. In the late 1980s, a chytridiomycosis outbreak caused multiple frog species in Australia's Wet Tropics to decline. Populations of some species (e.g., Litoria nannotis) subsequently recovered, while others (e.g., Litoria dayi) did not. We examined the population genetics and current infection status of L. dayi, to test several hypotheses regarding the failure of its populations to recover: (1) a lack of individual dispersal abilities has prevented recolonization of previously occupied locations, (2) a loss of genetic variation has resulted in limited adaptive potential, and (3) L. dayi is currently adapting to chytridiomycosis. We found moderate-to-high levels of gene flow and diversity (Fst range: <0.01-0.15; minor allele frequency (MAF): 0.192-0.245), which were similar to previously published levels for recovered L. nannotis populations. This suggests that dispersal ability and genetic diversity do not limit the ability of L. dayi to recolonize upland sites. Further, infection intensity and prevalence increased with elevation, suggesting that chytridiomycosis is still limiting the elevational range of L. dayi. Outlier tests comparing infected and uninfected individuals consistently identified 18 markers as putatively under selection, and several of those markers matched genes that were previously implicated in infection. This suggests that L. dayi has genetic variation for genes that affect infection dynamics and may be undergoing adaptation.