Evaluation of the Diversity, Equity, and Inclusion Curriculum of a Pediatrics Residency Program.

OBJECTIVES: Diversity, equity, and inclusion (DEI) training is essential to graduate medical education, but it lacks standardization. Although the impact of providers' biases and cultural competency on patient outcomes is well documented, the value of and satisfaction with DEI curricula in Pediatrics residency training programs is not well studied. This study aimed to complete a cross-sectional evaluation of the current DEI curriculum at a large Pediatrics-focused academic institution and identify areas of perceived deficiency among Pediatrics trainees. METHODS: Residents and residency program directors completed surveys in 2020. Respondents evaluated the DEI curriculum of the program and the competency of residents to complete patient care related to specific DEI-oriented actions. Our analysis used descriptive statistics. RESULTS: In total, 48 of 137 resident trainees (35%) and 7 of 9 program leaders (78%) completed the survey. Respondents were most dissatisfied with current education related to implicit bias, refugee/immigrant health, and lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other health topics. Respondents reported low resident competency in DEI-focused patient care tasks and did not view residents as competent to address the healthcare needs of patients and families experiencing racism. CONCLUSIONS: Pediatrics residents and program directors consider DEI topics important and express a need for more robust DEI curricula.

Successful 2-Stage Pacemaker Implantation for Atrioventricular Block in a Low-Birth-Weight Infant with Congenital Heart Disease: Case Report.

Congenital heart block is a potentially life-threatening condition with high morbidity and mortality, especially in the presence of congenital heart disease. We present the case of a low-body-weight premature infant with complex single ventricle congenital heart disease and high-grade atrioventricular block. A 2-staged pacing approach provided atrio-ventricular synchrony and allowed her to grow until a permanent dual-chamber pacemaker system could be implanted.

Outcomes for Young Adults With Suicide Admitted to Adult Versus Pediatric Hospitals.

OBJECTIVES: To evaluate differences in care and outcomes for young adults admitted with suicide ideation (SI) or attempt (SA) to medical units of an adult (AH) versus pediatric hospital (PH). METHODS: Demographic and clinical characteristics were collected on patients aged 18 to 25 years admitted to either an AH or PH at an academic health system from September 2017 through June 2023 with a diagnosis of SI or SA. Outcomes measured were discharge location, length of stay (LOS), emergency department (ED) visit or hospital readmission, and inpatient consultations. Bivariate tests and multivariate regression were used to determine association of admission location and outcomes. RESULTS: Of 212 patients included, 54% were admitted to an AH and 46% to a PH. Admission to a PH compared with an AH was associated with shorter ED LOS (4.3 vs 7.3 hours, P < .01) and discharge to home (57% vs 42%, P = .028) on bivariate but not adjusted analysis. Admission location was not associated with hospital LOS, ED visit or medical readmission after discharge, or psychiatry consultation. Admission to a PH compared with an AH was associated with higher odds of psychology consultation (29 vs 3%, P < .01). CONCLUSIONS: Although young adults admitted to a PH for SI/SA had higher rates of psychology consultation, they otherwise had similar care and outcomes regardless of admission to an AH versus a PH. Further work is needed to determine if observed differences are generalizable and how they affect hospital throughput and long-term outcomes.

Fluid overload in infants following congenital heart surgery.

OBJECTIVE: To describe postoperative fluid overload patterns and correlate degree of fluid overload with intensive care morbidity and mortality in infants undergoing congenital heart surgery. DESIGN: Prospective, observational study. Fluid overload (%) was calculated by two methods: 1) (Total fluid in - Total fluid out)/(Preoperative weight) × 100; and 2) (Current weight - Preoperative weight)/(Preoperative weight) × 100. Composite poor outcome included: need for renal replacement therapy, upper quartile time to extubation or intensive care length of stay (> 6.5 and 9.9 days, respectively), or death ≤ 30 days after surgery. SETTING: University hospital pediatric cardiac ICU. PATIENTS: Forty-nine infants < 6 months of age undergoing congenital heart surgery with cardiopulmonary bypass during the period of July 2009 to July 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients had a median age of 53 days (21 neonates) and mean weight of 4.5 ± 1.3 kg. Forty-two patients (86%) developed acute kidney injury by meeting at least Acute Kidney Injury Network and Kidney Disease Improving Global Outcomes stage 1 criteria (serum creatinine rise of 50% or ≥ 0.3mg/dL). The patients with adverse outcomes (n = 17, 35%) were younger (7 [5 - 10] vs. 98 [33 - 150] days, p = 0.001), had lower preoperative weight (3.7 ± 0.7 vs. 4.9 ± 1.4 kg, p = 0.0002), higher postoperative mean peak serum creatinine (SCr) (0.9 ± 0.3 vs. 0.6 ± 0.3mg/dL, p = 0.005), and higher mean maximum fluid overload by both method 1 (12% ± 10% vs. 6% ± 4%, p = 0.03) and method 2 (24% ± 15% vs. 14% ± 8%, p = 0.02). Predictors of a poor outcome from multivariate analyses were cardiopulmonary bypass time, use of circulatory arrest, and increased vasoactive medication requirements postoperatively. CONCLUSIONS: Early postoperative fluid overload is associated with suboptimal outcomes in infants following cardiac surgery. Because the majority of patients developed kidney injury without needing renal replacement therapy, fluid overload may be an important risk factor for adverse outcomes with all degrees of acute kidney injury.

The Autonomy Toolbox: A Multicenter Collaborative to Promote Resident Autonomy.

OBJECTIVES: Autonomy is necessary for resident professional development and well-being. A recent focus on patient safety has increased supervision and decreased trainee autonomy. Few validated interventions exist to improve resident autonomy. We aimed to use quality improvement methods to increase our autonomy metric, the Resident Autonomy Score (RAS), by 25% within 1 year and sustain for 6 months. METHODS: We developed a bundled-intervention approach to improve senior resident (SR) perception of autonomy on Pediatric Hospital Medicine (PHM) services at 5 academic children's hospitals. We surveyed SR and PHM faculty perceptions of autonomy and targeted interventions toward areas with the highest discordance. Interventions included SR and faculty development, expectation-setting huddles, and SR independent rounding. We developed a Resident Autonomy Score (RAS) index to track SR perceptions over time. RESULTS: Forty-six percent of SRs and 59% of PHM faculty completed the needs assessment survey querying how often SRs were afforded opportunities to provide autonomous medical care. Faculty and SR ratings were discordant in these domains: SR input in medical decisions, SR autonomous decision-making in straightforward cases, follow-through on SR plans, faculty feedback, SR as team leader, and level of attending oversight. The RAS increased by 19% (3.67 to 4.36) 1 month after SR and faculty professional development and before expectation-setting and independent rounding. This increase was sustained throughout the 18-month study period. CONCLUSIONS: SRs and faculty perceive discordant levels of SR autonomy. We created an adaptable autonomy toolbox that led to sustained improvement in perception of SR autonomy.

Thoracoscopic Resection of Left Atrial Appendage Aneurysm in a 16-Year-Old Boy.

We report a case of a left atrial appendage aneurysm (LAAA) in a 16-year-old boy presenting with supraventricular tachycardia (SVT). The aneurysm was detected incidentally on a routine echocardiogram performed before an electrophysiology study for evaluation and management of the SVT. The aneurysm was successfully resected under cardiopulmonary bypass through video-assisted thoracoscopic surgery. This type of surgery is a useful approach for LAAA in the pediatric population.

Arrhythmogenic channelopathy syndromes presenting as refractory epilepsy.

BACKGROUND: Children and young adults with potentially lethal cardiac channelopathies often present to medical care with a history of syncope or seizures due to episodic ventricular arrhythmias and associated cerebral hypoperfusion. METHODS: Two important types of genetic arrhythmia syndromes-long QT syndrome and catecholaminergic polymorphic ventricular tachycardia-are discussed using relevant case examples. The pathophysiology and distinguishing clinical features of these conditions are reviewed. RESULTS: The patients in each case were ultimately diagnosed with a cardiac channelopathy as the cause for their syncope and refractory seizures. With appropriate medical management, no further events have occurred to date. CONCLUSIONS: Cardiac channelopathies can be misdiagnosed as refractory epilepsy when in fact these events represent convulsive syncopes. Knowledge of and suspicion for these arrhythmogenic conditions may expedite diagnosis and improve outcomes.

Urinary biomarkers and renal near-infrared spectroscopy predict intensive care unit outcomes after cardiac surgery in infants younger than 6 months of age.

OBJECTIVE: To assess the ability of urinary acute kidney injury biomarkers and renal near-infrared spectroscopy (NIRS) to predict outcomes in infants after surgery for congenital heart disease. METHODS: Urinary levels of neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18), kidney injury molecule-1 (KIM-1), and cystatin C were measured preoperatively and postoperatively in 49 infants younger than 6 months of age. Renal NIRS was monitored for the first 24 hours after surgery. A composite poor outcome was defined as death, the need for renal replacement therapy, prolonged time to first extubation, or prolonged intensive care unit length of stay. RESULTS: Forty-two (86%) patients had acute kidney injury as indicated by at least Acute Kidney Injury Network/Kidney Disease: Improving Global Outcomes (AKIN/KDIGO) stage 1 criteria, and 17 (35%) patients had poor outcomes, including 3 deaths. With the exception of KIM-1, all biomarkers demonstrated significant increases within 24 hours postoperatively among patients with poor outcomes. Low levels of NGAL and IL-18 demonstrated high negative predictive values (91%) within 2 hours postoperatively. Poor outcome infants had greater cumulative time with NIRS saturations less than 50% (60 vs 1.5 minutes; P = .02) in the first 24 hours. CONCLUSIONS: Within the first 24 hours after cardiopulmonary bypass, infants at increased risk for poor outcomes demonstrated elevated urinary NGAL, IL-18, and cystatin C and increased time with low NIRS saturations. These findings suggest that urinary biomarkers and renal NIRS may differentiate patients with good versus poor outcomes in the early postoperative period, which could assist clinicians when counseling families and inform the development of future clinical trials.