Performance of Febrile Infant Decision Tools on Hypothermic Infants Evaluated for Infection.

BACKGROUND: Given the lack of evidence-based guidelines for hypothermic infants, providers may be inclined to use febrile infant decision-making tools to guide management decisions. Our objective was to assess the diagnostic performance of febrile infant decision tools for identifying hypothermic infants at low risk of bacterial infection. METHODS: We conducted a secondary analysis of a retrospective cohort study of hypothermic (≤36.0 C) infants ≤90 days of age presenting to the emergency department or inpatient unit among 9 participating sites between September 1, 2016 and May 5, 2021. Well-appearing infants evaluated for bacterial infections via laboratory testing were included. Infants with complex chronic conditions or premature birth were excluded. Performance characteristics for detecting serious bacterial infection (SBI; urinary tract infection, bacteremia, bacterial meningitis) and invasive bacterial infection (IBI; bacteremia, bacterial meningitis) were calculated for each tool. RESULTS: Overall, 314 infants met the general inclusion criteria, including 14 cases of SBI (4.5%) and 7 cases of IBI (2.2%). The median age was 5 days, and 68.1% of the infants (214/314) underwent a full sepsis evaluation. The Philadelphia, Boston, IBI Score, and American Academy of Pediatrics Clinical Practice Guideline did not misclassify any SBI or IBI as low risk; however, they had low specificity and positive predictive value. Rochester and Pediatric Emergency Care Applied Research Network tools misclassified infants with bacterial infections. CONCLUSIONS: Several febrile infant decision tools were highly sensitive, minimizing missed SBIs and IBIs in hypothermic infants. However, the low specificity of these decision tools may lead to unnecessary testing, antimicrobial exposure, and hospitalization.

Important Advances in Pediatric Injury Prevention.

In children, injuries are the leading cause of death, a major source of disability, and the number one cause of death for children after the first year of life. The principles of injury prevention include surveillance, coalitions, communication, interventions, and evaluation. This article discusses a number of common pediatric injuries and their prevention strategies. This review article addresses key components of injury prevention and specifically addresses the following injuries: motor vehicle crashes (with a section on teen driver crashes, sleep-related injury, and death), poisoning, all-terrain vehicle crashes, drowning, and firearm injuries. Injuries are preventable occurrences that can result in devastating sequelae or death. We present an overview of the more common pediatric injuries along with injury-prevention strategies.

Infant Safe Sleep Knowledge, Attitudes, and Behaviors by Physicians at an Academic Children's Hospital.

Sudden unexpected infant death (SUID) is the leading cause of death for infants. Physician advice on safe sleep is an important source of information for families. We sought to evaluate the safe sleep knowledge, attitudes, and behaviors of physicians by distributing a cross-sectional survey at a freestanding children's hospital. The survey included demographics, knowledge items, attitudinal assessment, and frequency of providing safe sleep guidance. Multivariable linear regression and logistic regression were used to evaluate associations between variables. 398 physicians were surveyed with 124 responses (31%). Females, those who received safe sleep training, and those who see infants in daily practice had higher knowledge scores. Physicians with higher knowledge scores had more positive attitudes toward safe sleep and provided safe sleep education to patients more often. Our study underlies the importance of education and repeated exposure in forming positive attitudes toward safe sleep recommendations and leads to increased provision of safe sleep guidance.

Improving Adherence to Safe Sleep Guidelines for Hospitalized Infants at a Children's Hospital.

INTRODUCTION: Sudden unexpected infant deaths are a major problem nationally. We had poor adherence to safe sleep recommendations locally at our institution. Given the significance of this problem, hospital administration at a tertiary children's hospital tasked a multidisciplinary group of faculty and staff with improving sleep environments for hospitalized infants. METHODS: Our safe sleep task force implemented targeted interventions using the American Academy of Pediatrics policy statement as the gold standard and based on hospital data to address areas of greatest nonadherence to recommendations. We aimed to improve weekly average adherence to 95% over 12 months. A proportions process control chart (p-chart) tracked average weekly adherence over a 52-week time frame. In addition, we performed Student's t-testing to evaluate differences in adherence over time. RESULTS: There was a significant improvement in overall adherence to safe sleep recommendations from baseline (M = 70.8%, SD 21.6) to end of study period (M = 94.7%, SD 10.0) [t(427) = -15.1, P ≤ 0.001]. Crib audits with 100% adherence increased from a baseline (M = 0%, SD 0) to the end of the study period M = 70.4%, SD = 46) [t(381)= -21.4, P ≤ 0.001]. This resulted in two trend shifts on the p-chart using Institute for Healthcare Improvement control chart rules. CONCLUSIONS: Targeted interventions using QI methodology led to significant increases in adherence to safe sleep guidelines. Notable improvements in behavior indicated significant changes in safe sleep culture. We also noted continued adherence in follow-up audits reflecting sustainability.

Acute Appendicitis Associated With Multisystem Inflammatory Syndrome in Children.

Multisystem inflammatory syndrome in children (MIS-C) has been reported to cause significant gastrointestinal symptoms. In this case series, we present four patients with MIS-C with documented acute appendicitis, which strengthens the association between SARS-CoV-2, MIS-C, and acute appendicitis.

What Defines an Honors Student? Survey of Pediatric and Internal Medicine Faculty Perspectives.

OBJECTIVE: Although considerable emphasis is placed on the attainment of honors in core medical school clerkships, little is known about what student characteristics are used by attending physicians to earn this designation. The purpose of this study was to evaluate what values and characteristics that attending physicians consider important in the evaluation of Pediatrics and Internal Medicine clerkship students for clinical honors designation. METHODS: This cross-sectional survey study was framed around Accreditation Council for Graduate Medical Education (ACGME) competencies. It was administered at three tertiary care hospitals associated with one large medical school in an urban setting. Teaching ward attendings in Pediatrics and Internal Medicine who evaluated third-year medical students between 2013 and 2016 were surveyed. RESULTS: Overall, Pediatric and Internal Medicine faculty demonstrated close agreement in which competencies were most important in designating clinical honors. Both groups believed that professionalism was the most important factor and that systems-based practice and patient care were among the least important factors. The only competency with a significant difference between the two groups was systems-based practice, with Internal Medicine placing more emphasis on the coordination of patient care and understanding social determinants of health. CONCLUSIONS: Professionalism, communication skills, and medical knowledge are the most important characteristics when determining clinical honors on Pediatrics and Internal Medicine clerkships.

Which Student Characteristics Are Most Important in Determining Clinical Honors in Clerkships? A Teaching Ward Attending Perspective.

PURPOSE: To explore faculty perspectives on which characteristics of high-performing clerkship students are most important when determining an honors or top grade designation for clinical performance. METHOD: In 2016-2017, the authors surveyed faculty (teaching ward attendings) for internal medicine clerkships and 1 pediatrics clerkship in inpatient settings at 5 U.S. academic medical centers. Survey items were framed around competencies, 24 student characteristics, and attitudes toward evaluation. Factor analysis examined constructs defining high-performing students. RESULTS: Of 516 faculty invited, 319 (62%) responded. The top 5 characteristics as rated by respondents were taking ownership, clinical reasoning, curiosity, dependability, and high ethical standards (in descending order). Twenty-one characteristics fit into 3 factors (Cronbach alpha, 0.81-0.87). Clinical reasoning did not fit into a factor. Factor 1 was the most important (mean rating, 8.7/10 [95% confidence interval (CI), 8.6-8.8]). It included professionalism components (ownership, curiosity, dependability, high ethical standards), presentation and interviewing skills, seeking feedback, and documentation. Factor 2 (mean, 7.9 [95% CI, 7.7-8.0]) included aspects of teamwork and communication, such as positive attitude and comments from others. Factor 3 (mean, 7.6 [95% CI, 7.4-7.7]) addressed systems-based thinking, including patient safety and care transitions. CONCLUSIONS: Professionalism components, clinical reasoning, and curiosity were among the most important characteristics distinguishing high-performing clerkship students. These may represent behaviors that are highly valued, observable, and relevant to training stage. Improved definition of the characteristics associated with clinical honors would assist students, faculty, and residency program directors when interpreting clinical performance within core clerkships.

Quality Improvement Project to Improve Screening for Tobacco Use in Adolescent Inpatients at a Children's Hospital.

Tobacco use begins in adolescence for the majority of smokers. The purpose of this study was to increase screening and reporting of tobacco use in hospitalized adolescents at a tertiary care children's hospital. We completed a nursing focus group to understand challenges and completed four iterative Plan-Do-Study-Act cycles, which included: (1) in-person nursing education regarding tobacco use screening, (2) addition of an e-cigarette-specific screening question, (3) the creation and dissemination of an educational video for nursing, and (4) adding the video as a mandatory component of nursing orientation. Run charts of the percentage of patients screened who reported tobacco use were created. Absolute counts of tobacco products used were also captured. From January 2016 to September 2018, 12,999 patients ≥13 years of age were admitted to the hospital. At baseline, 90.1% of patients were screened and 4.8% reported tobacco use. While the absolute number of adolescents reporting e-cigarette use increased from zero patients per month at baseline to five, the percentage of patients screened and reporting tobacco use was unchanged; the majority of e-cigarette users reported use of other tobacco products. This study demonstrates that adding e-cigarettes to screening increases reporting and suggests systems level changes are needed to improve tobacco use reporting.

Identifying High-Performing Students in Inpatient Clerkships: A Qualitative Study.

OBJECTIVES: Examine fundamental behaviors and characteristics that attending physicians in inpatient settings utilize to identify high-performing clerkship students. METHODS: We employed written comment data from a cross-sectional survey of Internal Medicine and Pediatrics attending physicians at a single academic medical center in the southern USA. Free-text responses regarding factors that faculty consider when assigning honors grades were analyzed by four trained researchers (interrater agreement 0.87) using conventional content analysis to identify themes. RESULTS: Seventy-nine of 141 (56%) attending physicians who were surveyed provided 90 comments.Four major theme areas for recognizing higher performing clerkship students were identified: Taking Ownership of Patient Care (35%), Medical Knowledge and Clinical Reasoning (20%), Team Orientation (15%), and Awareness of Opportunities for Growth and Progress (13%). CONCLUSION: Internal Medicine and Pediatric attending physicians identified characteristics that contributed to four themes in the determination of a high-performing medical student. These findings are particularly salient, as they highlight that commitment to patients, application of clinical knowledge and skills, teamwork, and awareness of growth and progress are valued by attending physicians for identifying top performing students in inpatient settings.

Fulminant Haemophilus Influenzae Type a Infection in a 4-year-old with Previously Undiagnosed Asplenic Heterotaxy.

The post Hib-vaccine era has resulted in increased cases of invasive, non-Hib, Haemophilus influenzae infections. One of the encapsulated species, type a, displays the most similarity in virulence to type b. Our patient, a fully vaccinated 4-year-old female, with newly diagnosed asplenia in the setting of heterotaxy, had a prolonged hospital course with disseminated Haemophilus influenzae type a infection.