Challenges in defining surgical-site infections following hydrocephalus surgeries.

Multiple organizations track neurosurgical surgical-site infection (SSI) rates, but significant variation exists among reporting criteria. We report our center's experience with the variation in cases captured by 2 major definitions. Standardization could support improvement activities and SSI reduction.

Development and Implementation of a Practical Onboarding Curriculum for Physician Quality and Safety Leaders.

Physicians are increasingly asked to assume quality and safety (Q&S) leadership roles; prior experience varies, and onboarding training is limited. Semistructured interviews were completed with physician Q&S leaders; interview responses were analyzed using 2-step rapid analysis. Interview learnings informed development of a 2-day onboarding training and complementary digital resource repository. Attendees were surveyed to evaluate the training. Thirteen semistructured interviews with physician leaders from 6 academic medical centers demonstrated 61.5% had no formal Q&S training before assuming their role. Respondents identified a range of knowledge gaps. A 2-day virtual onboarding training and complementary digital repository were created. Attendee surveys demonstrated 96% (73/76) believed the training would be "extremely" or "moderately" helpful to others. Subject-matter familiarity across all content areas improved after the training. Using front-line stakeholder input, a pilot onboarding curriculum for Q&S leaders was created. Future work includes ongoing implementation and iterative improvement.

Impact of a Documented Penicillin Allergy on Antibiotic Selection in Pediatric Patients With Osteomyelitis.

Penicillin allergy labels are common in hospitalized patients, and there is a frequent misconception that these patients cannot receive cephalosporins. Through retrospective review, we found that patients with reported penicillin allergies were significantly less likely to receive first-line therapy for acute hematogenous osteomyelitis.

Utility of Broad-Range PCR Sequencing for Infectious Diseases Clinical Decision Making: a Pediatric Center Experience.

Broad-range PCR (BRPCR) sequencing is a promising tool for diagnosis of infectious conditions when traditional microbiologic strategies fail to identify a pathogen. Data on the optimal clinical scenarios in which to use this tool are limited. We assessed, via retrospective chart review, the rate of organism identification and impact on clinical management from BRPCR testing sent from our quaternary care children's hospital between February 2010 and June 2020. A total of 382 samples were sent from 269 individual patients. A total of 200 (74.3%) patients were immunocompromised. Median age at time of sample collection was 10.0 years (interquartile range, 4.2 to 15.8). A total of 254/377 (64.7%) samples were from patients known to be on ≥1 antimicrobial in the 24 h prior to sample collection. A total of 112/382 (29.3%) samples were from patients ultimately diagnosed with a bacterial or fungal infection by another testing modality. The most common sample types were bronchoalveolar lavage (BAL) fluid (45), lung tissue (41), and bone (39). An organism was identified from 83 (21.7%) samples, but results from only 19 (5.0%) samples led to a change in management. Organisms were identified from 18 (40%) BAL samples; only 2 (4.4%) were judged to be clinically significant. A total of 4/12 (33.3%) samples from cardiac hardware changed clinical management. We found that only 5% of BRPCR results influenced antimicrobial management in a diverse pediatric cohort. Our findings suggest that the impact on clinical management varied widely by sample type. Additional work is necessary to characterize the ideal clinical scenarios in which BRPCR should be used.

Going Virtual: Objective Structured Teaching Exercises as an Innovative Method for Formative Resident Education.

BACKGROUND: The coronavirus disease 2019 pandemic forced residency programs to adapt teaching to the virtual arena. Objective Structured Teaching Exercises (OSTEs) are a simulation-based session we previously implemented in our in-person pediatric curriculum. We aimed to assess feasibility of and resident satisfaction with the transition to virtual learning for simulation-based OSTEs. METHODS: The pediatrics residency program at our hospital has a weekly academic half-day for residents where the OSTEs were held annually in person 2018 to 2019 and virtually in 2020. Surveys were collected from participating residents and faculty to compare teaching experience, feedback quality, and satisfaction with the session. RESULTS: Over 3 academic years, there were 159 total teaching sessions, 3 of which were OSTEs. The OSTE session was highly rated each year and was the second highest rated virtual session. Residents felt the OSTEs improved their teaching regardless of the virtual versus in-person platform (P = .77), and the quality of feedback as rated by the resident teacher was higher for virtual sessions (P < .001). CONCLUSIONS: Transitioning the OSTE to a virtual platform was both feasible and effective when compared to the in-person OSTE. In the transition to virtual learning, educators should consider opportunities for simulation-based teaching such as OSTEs.

Improving Pediatric Residents' Screening for Access to Firearms in High-Risk Patients Presenting to the Emergency Department.

BACKGROUND/OBJECTIVE: Access to a firearm is a significant risk for completed suicide or homicide. We sought to increase the rate of screening for access to firearms in patients who presented to the emergency department with suicidal or homicidal ideation or suicide attempt through the use of quality improvement methodology. METHODS: Patient records were eligible for inclusion if the child was under the age of 19 and presented to the emergency room of our tertiary medical center with a diagnosis of suicidal ideation, homicidal ideation, or suicide attempt. Records were manually reviewed for demographic information and documentation of screening for access to firearms. A baseline survey of the pediatric residents was completed to identify perceived barriers to screening for access to firearms. Subsequently, three "Plan, Do, Study, Act" (PDSA) cycles consisting of a noon conference, a dedicated grand rounds, and an electronic health record template were completed. RESULTS: During the baseline and study period, 501 patients met inclusion criteria. Forty-one of sixty-six (62.1%) residents completed a baseline survey and identified barriers to screening. There was no significant increase in screening following the first or second PDSA cycles. Following the third PDSA cycle, screening rates increased from 4% to 34%. CONCLUSIONS: Quality improvement methodology can be used to increase the rates of screening for access to firearms in high-risk patients. Further work is necessary to identify additional strategies to further increase screening rates.

Non-SARS-CoV-2 Infections Among Patients Evaluated for MIS-C Associated With COVID-19.

Clinical features of Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 are nonspecific. In this retrospective cohort study of 39 patients evaluated for MIS-C, 11 had non-SARS-CoV-2 infections, 3 of whom were also diagnosed with MIS-C. Clinical features were similar in patients with MIS-C and patients with non-SARS-CoV-2 infections. Clinicians should consider non-SARS-CoV-2 infections in patients undergoing MIS-C evaluation.

Medication Education for Dosing Safety: A Randomized Controlled Trial.

STUDY OBJECTIVE: This study sought to determine whether a brief intervention at the time of emergency department (ED) discharge can improve safe dosing of liquid acetaminophen and ibuprofen by parents or guardians. METHODS: We performed a randomized controlled trial in the ED of parents and guardians of children 90 days to 11.9 years of age who were discharged with acetaminophen or ibuprofen, or both. Families were randomized to standard care or a teaching intervention combining lay language, simplified handouts, provision of an unmarked dosing syringe, and teach-back to confirm correct dosing. Participants were called 48 to 72 hours and 5 to 7 days after ED discharge to assess understanding of correct dosing. The primary outcome was defined as parent or guardian report of safe dosing at the time of first follow-up call. Our primary hypothesis was that the intervention would decrease the rate of error from 30% to 10% at 48- to 72-hour follow-up. RESULTS: We enrolled 149 of 259 (58%) eligible subjects; 97 of 149 (65%) were reached at first follow-up call, of whom 35 of 97 (36%) received the intervention. Among those participants receiving the intervention, 25 of 35 (71%) were able to identify a safe dose for their child at the time of the first call compared with 28 of 62 (45%) of those in the control arm. The difference in proportions was 26% (95% confidence interval [CI] 7% to 46%). There was a 58% increase in reporting safe dosing in the intervention group compared with the control roup (relative risk 1.58; 95% CI 1.12 to 2.24), and it remained significant after adjustment for health literacy and language (adjusted relative risk 1.50; 95% CI 1.06 to 2.13). CONCLUSIONS: A multifaceted intervention at the time of ED discharge-consisting of a simplified dosing handout, a teaching session, teach-back, and provision of a standardized dosing device-can improve parents' knowledge of safe dosing of liquid medications at 48 to 72 hours.

Case Report: Comparison of Plasma Metagenomics to Bacterial PCR in a Case of Prosthetic Valve Endocarditis.

Molecular assays for infectious diseases have emerged as important clinical decision-making tools. Unbiased, metagenomic next-generation sequencing is a novel approach holding promise to detect pathogens missed by conventional modalities and to deconvolute admixed nucleic acid sequences from polymicrobial infections in order to identify constituent pathogens. Recent studies have raised concerns about the clinical impact of metagenomics assays and whether their expense is justified. Here, we report a case of polyclonal Streptococcus cristatus endocarditis in a 14-year-old woman with a history of Tetralogy of Fallot. Three sets of admission blood cultures and a commercial plasma metagenomics assay were negative for pathogens, despite persistent vegetations observed on the valve during a later procedure. Multiple strains of Streptococcus cristatus were identified from the explanted valve by amplicon-based 16S rRNA sequencing, confirming the patient had received appropriate antibiotic therapy. This case highlights limitations in the use and interpretation of clinical metagenomics for infectious disease diagnosis and indicates that the clinical yield of these tools may depend upon infection type and anatomic location.

Screening for Access to Firearms by Pediatric Trainees in High-Risk Patients.

OBJECTIVE: Access to firearms is an independent risk factor for completed suicide and homicide, and the American Academy of Pediatrics recommends that pediatricians screen and counsel about firearm access and safe storage. This study investigates how often pediatric residents screen for access to firearms or counsel about risk-reduction in patients with suicidal or homicidal ideation. METHODS: Retrospective chart review of visits by patients younger than the age of 19 years presenting to the pediatric emergency department (ED) of a tertiary academic medical center from January to December 2016. Visits were eligible if there was an ultimate ED discharge diagnosis of "suicidal ideation," "suicide attempt," or "homicidal ideation" as identified by International Statistical Classification of Diseases and Related Health Problems, 10th revision codes and the patient was seen by a pediatric resident before evaluation by psychiatry. Descriptive statistics were used to analyze results. RESULTS: Ninety-eight patients were evaluated by a pediatric resident for medical assessment before evaluation by a psychiatry team during the study period and were therefore eligible for inclusion. Screening for firearm access was documented by a pediatric resident in 5 of 98 (5.1%) patient encounters. Twenty-five patients (25.5%) had no documented screening for firearm access by any provider during the ED visit, including in 5 cases when patients were discharged home. CONCLUSIONS: Pediatric residents rarely document screening for firearm access in patients with known suicidal or homicidal ideation who present to the ED. Additional understanding of the barriers to screening and potential strategies for improving screening and counseling are critical to providing appropriate care for high-risk pediatric patients.