Transition of care: lessons from the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) dialysis collaborative.

BACKGROUND: Acknowledging the importance of preparing the pediatric dialysis patient for successful transfer to adult providers, centers from the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Dialysis Collaborative developed transition tools and performed iterative implementation of a transition of care (TOC) program to gain real-life insight into drivers and barriers towards implementation of a transition program for patients receiving dialysis. METHODS: A TOC innovation workgroup was developed in 2019 from within SCOPE Collaborative that developed nine educational modules, along with introductory letter and assessment tool to be utilized by SCOPE centers. A 4-month pilot implementation study among six centers of varying patient population (age ≥ 11 years) was performed. TOC tools were further refined, and broader implementation within the collaborative was performed. Interim assessment of TOC tool utilization and implementation success was performed among 11 centers, as a foundation towards broader discussion regarding process, barriers, and success towards TOC implementation among 26 centers. RESULTS: Transition champion was a key driver of successful implementation, and lack of institutional support and collaboration with adult dialysis centers were important barriers towards sustainability. COVID pandemic and increased staff turnover affected longer term implementation of TOC program. CONCLUSIONS: Successful transition and transfer of adolescents/young adults with kidney failure on dialysis remains a challenge. This study represents the experience of the largest cohort of pediatric dialysis centers, with diversity in population size and geography, towards development and implementation of a TOC program. This adds to the resources available to assist centers towards transition and transfer, with particular focus on transitioning patients on dialysis.

Use of ClearGuard HD caps in pediatric hemodialysis patients.

BACKGROUND: Bloodstream infections (BSIs) are a leading cause of hospitalizations and mortality among patients receiving hemodialysis (HD) therapy, especially those with a central venous catheter (CVC) for dialysis access. The use of chlorhexidine impregnated catheter caps (ClearGuard) has been associated with a decrease in the rate of HD catheter-related BSIs (CA-BSIs) in adults; similar data have not been published for children. METHODS: We compared CA-BSI data from participating centers within the Standardizing Care to Improve Outcomes in Pediatric Endstage Kidney Disease (SCOPE) collaborative based on the center's use of ClearGuard caps for patients with HD catheter access. Centers were characterized as ClearGuard (CG) or non-ClearGuard (NCG) centers, with CA-BSI data pre- and post-CG implementation reviewed. All positive blood cultures in participating centers were reported to the SCOPE collaborative and adjudicated by an infectious disease physician. RESULTS: Data were available from 1786 SCOPE enrollment forms completed January 2016-January 2022. January 2020 served as the implementation date for analyzing CG versus NCG center data, with this being the time when the last CG center underwent implementation. Post January 2020, there was a greater decrease in the rate of HD CA-BSI in CG centers versus NCG centers, with a decrease from 1.18 to 0.23 and 0.41 episodes per 100 patient months for the CG and NCG centers, respectively (p = 0.002). CONCLUSIONS: Routine use of ClearGuard caps in pediatric dialysis centers was associated with a reduction of HD CA-BSI rates in pediatric HD patients.

Current Trends in Invasive Closure of Patent Ductus Arteriosus in Very Low Birth Weight Infants in United States Children's Hospitals, 2016-2021.

OBJECTIVE: To describe the current practices in invasive patent ductus arteriosus (PDA) closure (surgical ligation or transcatheter occlusion) in very low birth weight (VLBW) infants and changes in patient characteristics and outcomes from 2016 to 2021 among US children's hospitals. STUDY DESIGN: We evaluated a retrospective cohort of VLBW infants (birth weight 400-1499 g and gestational age 22-31 weeks) who had invasive PDA closure within 6 months of age from 2016 to 2021 in children's hospitals in the Pediatric Health Information System. Changes in patient characteristics and outcomes over time were evaluated using generalized linear models and generalized linear mixed models. RESULTS: 2418 VLBW infants (1182 surgical ligation; 1236 transcatheter occlusion) from 42 hospitals were included. The proportion of infants receiving transcatheter occlusion increased from 17.2% in 2016 to 84.4% in 2021 (P < .001). In 2021, 28/42 (67%) hospitals had performed transcatheter occlusion in > 80% of their VLBW infants needing invasive PDA closure, compared with only 2/42 (5%) in 2016. Although median postmenstrual age (PMA) at PDA closure did not change for the overall cohort, PMA at transcatheter occlusion decreased from 38 weeks in 2016 to 31 weeks by 2020, P < .001. Among those infants not intubated prior to PDA closure, extubation within 3 days postprocedure increased over time (yearly adjusted odds ratios of 1.26 [1.08-1.48]). Length of stay and mortality did not change over time. CONCLUSION: We report rapid adoption of transcatheter occlusion for PDA among VLBW infants in US children's hospitals over time. Transcatheter occlusions were performed at younger PMA over time.

Assessment of potential peritonitis risk factors in pediatric patients receiving maintenance peritoneal dialysis.

BACKGROUND: Many recommendations regarding peritonitis prevention in international consensus guidelines are opinion-based rather than evidence-based. The aim of this study was to examine the impact of peritoneal dialysis (PD) catheter insertion technique, timing of gastrostomy placement, and use of prophylactic antibiotics prior to dental, gastrointestinal, and genitourinary procedures on the risk of peritonitis in pediatric patients on PD. METHODS: We conducted a retrospective cohort study of pediatric patients on maintenance PD using data from the SCOPE collaborative from 2011 to 2022. Data pertaining to laparoscopic PD catheter insertion (vs. open), gastrostomy placement after PD catheter insertion (vs. before/concurrent), and no prophylactic antibiotics (vs. yes) were obtained. Multivariable generalized linear mixed modeling was used to assess the relationship between each exposure and occurrence of peritonitis. RESULTS: There was no significant association between PD catheter insertion technique and development of peritonitis (aOR = 2.50, 95% CI 0.64-9.80, p = 0.19). Patients who had a gastrostomy placed after PD catheter insertion had higher rates of peritonitis, but the difference was not statistically significant (aOR = 3.19, 95% CI 0.90-11.28, p = 0.07). Most patients received prophylactic antibiotics prior to procedures, but there was no significant association between prophylactic antibiotic use and peritonitis (aOR = 1.74, 95% CI 0.23-13.11, p = 0.59). CONCLUSIONS: PD catheter insertion technique does not appear to have a significant impact on peritonitis risk. Timing of gastrostomy placement may have some impact on peritonitis risk. Further study must be done to clarify the effect of prophylactic antibiotics on peritonitis risk. A higher resolution version of the Graphical abstract is available as Supplementary information.

Training practices and peritonitis rates in children on maintenance peritoneal dialysis: results from the Standardizing Care to Improve Outcomes in Pediatric End Stage Kidney Disease (SCOPE) collaborative.

BACKGROUND: Comprehensive training of children on peritoneal dialysis (PD) and their caregivers is crucial to minimize peritonitis risk. Few studies have evaluated the impact of training on infection, so many published recommendations rely on expert opinion. This study uses data from the SCOPE collaborative to examine the impact of compliance with 4 components of PD training on the risk for peritonitis. METHODS: A retrospective cohort study of children enrolled in the SCOPE collaborative between 2011 and 2021 who received training prior to initiating PD. Compliance with 4 training components were assessed: performance of a home visit, 1:1 training, delaying training ≥ 10 days after PD catheter insertion and average individual training session length ≤ 3 h. Univariate and multivariable generalized linear mixed modeling were used to assess relationships between peritonitis ≤ 90 days after PD training and median days to peritonitis and compliance with each component as well as all-or-none compliance. RESULTS: Among 1450 trainings, 51.7% had median session length ≤ 3 h, 67.1% delayed training ≥ 10 days after catheter insertion, 74.3% had a home visit and 94.6% had 1:1 training. Only 333 trainings (23%) were compliant with all 4 training components. There was no statistically significant association between compliance with individual components, or all-or-none compliance and either the percentage of catheters with peritonitis ≤ 90 days after training end or median days to peritonitis. CONCLUSION: No associations between 4 PD training components and risk for peritonitis were found. SCOPE requires monthly review of PD catheter practices which may have decreased the impact of training non-compliance. A higher resolution version of the Graphical abstract is available as Supplementary information.

Outcomes based on induction regimens in pediatric kidney transplantation: a NAPRTCS and PHIS collaborative study.

BACKGROUND: Induction agent used at the time of kidney transplant is often based upon center practice and recipient characteristics. We evaluated outcomes across induction therapies among children enrolled in the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) transplant registry with data in the Pediatric Health Information System (PHIS). METHODS: This is a retrospective study of merged data from NAPRTCS and PHIS. Participants were grouped by induction agent: interleukin-2 receptor blocker (IL-2 RB), anti-thymocyte/anti-lymphocyte globulin (ATG/ALG), and alemtuzumab. Outcomes assessed included 1-, 3-, and 5-year allograft function and survival, rejection, viral infections, malignancy, and death. RESULTS: A total of 830 children transplanted between 2010 and 2019. At 1 year post-transplant, the alemtuzumab group had higher median eGFR (86 ml/min/1.73 m2) compared to IL-2 RB and ATG/ALG (79 and 75 ml/min/1.73 m2, respectively; P < 0.001); at 3 and 5 years, there was no difference. Adjusted eGFR over time was similar across all induction agents. Rejection rates were lower among the alemtuzumab group vs. IL-2RB and ATG (13.9% vs. 27.3% and 24.6%, respectively; P = 0.006). Adjusted ATG/ALG and alemtuzumab had higher hazard ratio for time to graft failure compared to IL-2 RB (HR 2.48 and HR 2.11, respectively; P < 0.05). Incidence of malignancy, mortality, and time to first viral infection was similar. CONCLUSION: Although rejection and allograft loss rates were distinct, the incidences of viral infection and malignancy were comparable across induction agents. By 3 years post-transplant, there was no difference in eGFR. A higher resolution version of the Graphical abstract is available as Supplementary information.

The cost of hospitalizations for treatment of hemodialysis catheter-associated blood stream infections in children: a retrospective cohort study.

BACKGROUND: Hospitalization costs for treatment of hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) in adults are high. No studies have evaluated hospitalization costs for HD CA-BSI in children or identified factors associated with high-cost hospitalizations. METHODS: We analyzed 160 HD CA-BSIs from the Standardizing Care to Improve Outcomes in Pediatric End-stage Kidney Disease (SCOPE) collaborative database linked to hospitalization encounters in the Pediatric Health Information System (PHIS) database. Charge-to-cost ratios were used to convert hospitalization charges reported in PHIS database to estimated hospital costs. Generalized linear mixed modeling was used to assess the relationship between higher-cost hospitalization (cost above 50th percentile) and patient and clinical characteristics. Generalized linear regression models were used to assess differences in mean service line costs between higher- and lower-cost hospitalizations. RESULTS: The median (IQR) length of stay for HD CA-BSI hospitalization was 5 (3-10) days. The median (IQR) cost for HD CA-BSI hospitalization was $18,375 ($11,584-$36,266). ICU stay (aOR 5.44, 95% CI 1.62-18.26, p = 0.01) and need for a catheter procedure (aOR = 6.08, 95% CI 2.45-15.07, p < 0.001) were associated with higher-cost hospitalization. CONCLUSIONS: Hospitalizations for HD CA-BSIs in children are often multiple days and are associated with substantial costs. Interventions to reduce CA-BSI may reduce hospitalization costs for children who receive chronic HD. A higher resolution version of the Graphical abstract is available as Supplementary information.

Telehealth survey of providers and caregivers of children on peritoneal dialysis during the COVID-19 pandemic.

BACKGROUND: There has been growing support for the adoption of telehealth (TH) services in pediatric populations. Children on chronic peritoneal dialysis (PD) represent a vulnerable population that could benefit from increased use of TH. The COVID-19 pandemic prompted rapid adoption of TH services in the population among pediatric centers participating in The Children's Hospital Association's Standardizing Care to Improve Outcomes in Pediatric ESKD (SCOPE) Collaborative. METHODS: We developed a survey to explore the experience of both pediatric PD providers and caregivers of patients receiving PD care at home and using TH services during the COVID-19 pandemic. RESULTS: We obtained responses from 27 out of 53 (50.9%) SCOPE centers that included 175 completed surveys from providers and caregivers. Major challenges identified by providers included inadequate/lack of physical exam, inability to visit with the patient/family in-person, and inadequate/lack of PD catheter exit site exam. Only 51% of caregivers desired future TH visits; however, major benefits of TH for caregivers included no travel, visit takes less time, easier to care for other children, more comfortable for patient, and no time off from work. Providers and caregivers agreed that PD TH visits are family centered (p = 0.296), with the lack of a physical exam (p < 0.001) and the inability to meet in-person (p = 0.002) deemed particularly important to caregivers and providers, respectively. CONCLUSIONS: TH is a productive and viable visit option for children on PD; however, making this a successful, permanent part of routine care will require an individualized approach with standardization of core elements. A higher resolution version of the Graphical abstract is available as Supplementary information.

Survival of neonates born with kidney failure during the initial hospitalization.

BACKGROUND: Survival to hospital discharge in neonates born with kidney failure has not been previously described. METHODS: This was a retrospective, observational analysis of the Pediatric Health Information System (PHIS) database from 2005 to 2019. Primary outcome was survival at discharge; secondary outcomes were hospital and ICU length of stay (LOS). Univariate analysis was performed to describe the population by birth weight (BW) and characterize survival; multivariable generalized liner mixed modeling assuming a binomial distribution and logit link was performed to identify mortality risk factors. RESULTS: Of 213 neonates born with kidney failure (median BW 2714 g; GA 35 weeks; 68% male), 4 (1.9%) did not receive dialysis or peritoneal dialysis (PD) catheter placement, 152 (72.9%) received PD only, 49 (23.4%) received PD plus extracorporeal dialysis (ECD), and 8 (3.4%) were treated with an undocumented dialysis modality. Median age at dialysis initiation was 7 days; median hospital LOS and ICU LOS were 84 and 69 days, respectively. One-hundred and sixty-two patients (76%) survived to discharge. Non-survivors (n = 51) were more likely to have received ECD and mechanical ventilation, and had a longer duration of mechanical ventilation. Every day of mechanical ventilation increased the mortality odds by 2% (n = 189; adjusted OR 1.02; 1.01, 1.03); in addition, the odds of mortality were 2 times higher in those who received ECD vs. only PD (adjusted OR 2.25; 1.04, 4.86). CONCLUSIONS: Survival to initial hospital discharge occurs in the majority of neonates born with kidney failure. Predictors of increased mortality included longer duration of mechanical ventilation, as well as the requirement for ECD. A higher resolution version of the Graphical abstract is available as Supplementary information.

Pediatric peritoneal dialysis training program and its relationship to peritonitis: a study of the International Pediatric Peritoneal Dialysis Network.

BACKGROUND: The guidelines for training of patients and caregivers to perform home peritoneal dialysis (PD) uniformly include recommendations pertaining to the prevention of peritonitis. The objective of this study conducted by the International Pediatric Peritoneal Dialysis Network (IPPN) was to investigate the training practices for pediatric PD and to evaluate the impact of these practices on the peritonitis and exit-site infection (ESI) rate. METHODS: A questionnaire regarding details of the PD program and training practices was distributed to IPPN member centers, while peritonitis and ESI rates were either derived from the IPPN registry or obtained directly from the centers. Poisson univariate and multivariate regression was used to determine the training-related peritonitis and ESI risk factors. RESULTS: Sixty-two of 137 centers responded. Information on peritonitis and ESI rates were available from fifty centers. Training was conducted by a PD nurse in 93.5% of centers, most commonly (50%) as an in-hospital program. The median total training time was 24 hours, with a formal assessment conducted in 88.7% and skills demonstration in 71% of centers. Home visits were performed by 58% of centers. Shorter (< 20 hours) training duration and lower number of training tools (both p < 0.02) were associated with higher peritonitis rate, after adjustment for proportion of treated infants and income of country of residence. CONCLUSIONS: An association between training duration and the number of training tools represent potentially modifiable risk factors to reduce peritonitis rates within the pediatric PD population. A higher resolution version of the Graphical abstract is available as Supplementary information.

Risk Factors for Readmission Following Febrile Neutropenia in Pediatric Oncology Patients.

Febrile neutropenia is the most common reason for admission from the emergency department for pediatric oncology patients. We identified pediatric inpatients age 1 to 21 years with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code of malignancy and either fever with neutropenia or fever alone over a 6-year period (2007-2012) using the PHIS+ database. We evaluated factors associated with readmission within 7 days after index hospitalization. There were 4029 index hospitalizations among 2349 patients in 6 hospitals, 294 encounters (7.3%) were followed by readmission within 7 days. Factors associated with increased odds of readmission included being in the lowest quartile for median household income (odds ratio [OR]=1.64, P =0.009), diagnosis of acute lymphoblastic leukemia (OR=1.37, P =0.016), lack of anerobic coverage during index hospitalization (OR=1.48, P =0.026), and absolute neutrophil count <200 cells/µL at discharge from index hospitalizations (OR=1.55, P =0.008). Patients who required readmission had a longer median length of stay and greater hospitalization costs during the index hospitalization. There was a trend towards increasing hospitalization rates for febrile neutropenia over time. While absolute neutrophil count is incorporated into many risk stratification strategies for fever management, further work should focus on addressing socioeconomic factors which may impact readmission rates.

Epidemiology and Risk Factors for Hemodialysis Access-Associated Infections in Children: A Prospective Cohort Study From the SCOPE Collaborative.

RATIONALE & OBJECTIVE: Infections cause significant morbidity and mortality for children receiving maintenance hemodialysis (HD). The Standardizing Care to Improve Outcomes in Pediatric End-Stage Kidney Disease (SCOPE) Collaborative is a quality-improvement initiative aimed at reducing dialysis-associated infections by implementing standardized care practices. This study describes patient-level risk factors for catheter-associated bloodstream infections (CA-BSIs) and examines the association between dialysis center-level compliance with standardized practices and risk of CA-BSI. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: Children enrolled in SCOPE between June 2013 and July 2019. EXPOSURES: Data were collected on patient characteristics and center-level compliance with HD catheter care practices across the study period. Centers were categorized as consistent, dynamic (improved compliance over the study period), or inconsistent performers based on frequency of compliance audit submission and changes in compliance with HD care practices over time. OUTCOME: CA-BSIs. ANALYTICAL APPROACH: Generalized linear mixed models were used to evaluate (1) patient-level risk factors for CA-BSI and (2) associations between change in center-level compliance and CA-BSIs. RESULTS: The cohort included 1,277 children from 35 pediatric dialysis centers; 1,018 (79.7%) had a catheter and 259 (20.3%) had an arteriovenous fistula or graft. Among children with a catheter, mupirocin use at the catheter exit site was associated with an increased rate of CA-BSIs (rate ratio [RR], 4.45; P = 0.004); the use of no antibiotic agent at the catheter exit site was a risk factor of borderline statistical significance (RR, 1.79; P = 0.05). Overall median compliance with HD catheter care practices was 87.5% (IQR, 77.3%-94.0%). Dynamic performing centers showed a significant decrease in CA-BSI rates over time (from 2.71 to 0.71 per 100 patient-months; RR, 0.98; P < 0.001), whereas no significant change in CA-BSI rates was detected among consistent or inconsistent performers. LIMITATIONS: Lack of data on adherence to HD care practices on the individual patient level. CONCLUSIONS: Improvement in compliance with standardized HD care practices over time may lead to a reduction in dialysis-associated infections.

Association Between the First-Hour Intravenous Fluid Volume and Mortality in Pediatric Septic Shock.

STUDY OBJECTIVE: To determine whether the receipt of more than or equal to 30 mL/kg of intravenous fluid in the first hour after emergency department (ED) arrival is associated with sepsis-attributable mortality among children with hypotensive septic shock. METHODS: This is a retrospective cohort study set in 57 EDs in the Improving Pediatric Sepsis Outcomes quality improvement collaborative. Patients less than 18 years of age with hypotensive septic shock who received their first intravenous fluid bolus within 1 hour of arrival at the ED were propensity-score matched for probability of receiving more than or equal to 30 mL/kg in the first hour. Sepsis-attributable mortality was compared. We secondarily evaluated the association between the first-hour fluid volume and sepsis-attributable mortality in all children with suspected sepsis in the first hour after arrival at the ED, regardless of blood pressure. RESULTS: Of the 1,982 subjects who had hypotensive septic shock and received a first fluid bolus within 1 hour of arrival at the ED, 1,204 subjects were propensity matched. In the matched patients receiving more than or equal to 30 mL/kg of fluid, 26 (4.3%) of 602 subjects had 30-day sepsis-attributable mortality compared with 25 (4.2%) of 602 receiving less than 30 mL/kg (odds ratio 1.04, 95% confidence interval 0.59 to 1.83). Among the patients with suspected sepsis regardless of blood pressure, 30-day sepsis-attributable mortality was 3.0% in those receiving more than or equal to 30 mL/kg versus 2.0% in those receiving less than 30 ml/kg (odds ratio 1.52, 95% confidence interval 0.95 to 2.44.) CONCLUSION: In children with hypotensive septic shock receiving a timely first fluid bolus within the first hour of ED care, receiving more than or equal to 30 mL/kg of bolus intravenous fluids in the first hour after arrival at the ED was not associated with mortality compared with receiving less than 30 mL/kg.

Acute Care Utilization and Health Care Expenditures in Medicaid-Enrolled Children.

OBJECTIVES: Although recent health care reform efforts have focused on minimizing high cost health care utilization, the relationship between acute care use and health care expenditures among certain vulnerable populations such as Medicaid-insured children remains poorly understood. We sought to evaluate the association between acute care utilization and health care expenditures and to identify characteristics associated with high spending. METHODS: We performed a retrospective cohort study of Medicaid-enrolled children 1-21 years old from 1/1/2016 to 12/31/2016. Children were categorized by acute care use (including emergency department and urgent care visits) as 0, 1, 2, 3, and 4 or more visits. Our main outcomes were annualized spending, total per-member-per-year spending, and acute care-related per-member-per-year spending. RESULTS: There were 5.1 million Medicaid-enrolled children that comprised the study cohort, accounting for US $32.6 billion in total spending. Children with 4 or more acute care visits were more likely to be younger than 2 years or older than 14 years, female, and have a chronic condition. Children with 4 or more acute care visits consisted of only 4% of the cohort but accounted for 15% (US $4.7 billion) of the total spending. Increasing acute care visits were associated with increasing total annualized spending in adjusted analyses (P < 0.001). This association was disproportionately observed in older age groups and children without chronic medical conditions. CONCLUSIONS: Medicaid spending for children increases with increasing acute care use; this trend was disproportionately observed in older age groups and children without chronic medical conditions. Improved understanding of factors contributing to frequent acute care utilization and disproportionate spending is needed to potentially reduce unnecessary health care costs in these pediatric populations.

Continued reduction in peritonitis rates in pediatric dialysis centers: results of the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative.

BACKGROUND: In its first 3 years, the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative demonstrated a statistically significant increase in the likelihood of compliance with a standardized follow-up care bundle and a significant reduction in peritonitis. We sought to determine if compliance with care bundles and low peritonitis rates could be sustained in centers continuously participating for 84 months. METHODS: Centers that participated from collaborative launch through the 84-month study period and provided pre-launch peritonitis rates were included. Children on maintenance peritoneal dialysis were eligible for enrollment. Changes in bundle compliance were assessed using a logistic regression model or a generalized linear mixed model (GLMM). Changes in average annualized peritonitis rates over time were modeled using GLMMs. RESULTS: Nineteen centers contributed 1055 patients with 1268 catheters and 17,247 follow-up encounters. The likelihood of follow-up compliance increased significantly over the study period (OR 1.05 95% confidence interval (CI) 1.03, 1.07; p < 0.001). Centers achieved ≥ 80% follow-up bundle compliance by 28 months and maintained a mean compliance of 84% between 28 and 84 months post-launch. Average monthly peritonitis rates decreased from 0.53 (95% CI 0.37, 0.70) infections per patient-year pre-launch to 0.30 (95% CI 0.23, 0.43) at 84 months post-launch, p < 0.001. CONCLUSIONS: Centers participating in the SCOPE Collaborative for 84 months achieved and maintained a high level of compliance with a standardized follow-up care bundle and demonstrated a significant and continued reduction in average monthly peritonitis rates.

A comparison of the buttonhole and rope-ladder AVF cannulation techniques and infection rates within the SCOPE collaborative.

BACKGROUND: Studies regarding hemodialysis (HD) arteriovenous fistula (AVF) cannulation in adults indicate a higher risk of infection with the buttonhole (BH) technique compared to the rope-ladder (RL) technique. Pediatric data on this issue is sparse. METHODS: We compared infection rates within the Standardizing Care to Improve Outcomes in Pediatric End stage kidney disease (SCOPE) centers performing BH cannulation versus RL cannulation of AVF. Generalized linear mixed modeling was used to assess differences in access-related blood stream infection (BSI) and access site infection (ASI) rates between the centers. RESULTS: Data was available from 211 AVF enrollments among 210 children. There were 61 AVF enrollments at 6 BH centers and 150 enrollments at 13 RL centers. Demographics were similar between the two groups. There were 12 total infections in 3383 patient months. BH centers had 3 infections (0 BSI, 3 ASI) and RL centers had 9 infections (5 BSI, 3 ASI). Mean [95% confidence interval] infection rates per 1000 patient months were not different between BH and RL centers (BH: 3.1 [0.6,15.6], RL: 3.2 [1.3,9.4], p = 0.947). A survey was also completed by the BH centers to describe their BH practices. The BH procedure at the majority of sites was characterized by a small patient/nurse ratio and strict antiseptic protocols. CONCLUSIONS: This data provides evidence of a low BSI rate associated with BH cannulation in pediatric HD patients. Further studies are needed to better delineate the differences in the pediatric and adult experience with the BH cannulation technique.

Reliance on Acute Care Settings for Health Care Utilization: A Comparison of Adolescents With Younger Children.

OBJECTIVE: Because a goal of the Affordable Care Act was to increase preventive care and reduce high-cost care, the objective of this study was to evaluate current health care use and reliance on acute care settings among Medicaid-enrolled children. METHODS: This was a retrospective cohort study of the 2015 Truven Marketscan Medicaid claims database among children 0 to 21 years old with at least 11 months of continuous enrollment. We calculated adjusted probabilities of health care use (any health care use and ≥1 health maintenance visit) and high acute care reliance (ratio of emergency department or urgent care visits to all health care visits >0.33) by age and compared use between adolescents and younger children using multivariable logistic regression. RESULTS: Of the 5,182,540 Medicaid-enrolled children, 18.9% had no health care visits and 47.3% had 1 or more health maintenance visit in 2015. Both health care use and health maintenance visits decreased with increasing age (P < 0.001). Compared with younger children (0-10 years old), adolescents were more likely to have no interaction with the health care system [adjusted odds ratio (aOR), 2.20; 95% confidence interval (CI), 2.19-2.21] and less likely to have health maintenance visits (aOR, 0.40; 0.39-0.40). High acute care reliance was associated with increasing age, with adolescents having greater odds of high acute care reliance (aOR, 1.08; 1.08-1.09). CONCLUSIONS: Medicaid-enrolled adolescents have low rates of health care use and have high reliance on acute care settings. Further investigation into adolescent-specific barriers to health maintenance care and drivers for acute care is warranted.

Acute kidney injury in paediatric patients with sickle cell disease is associated with increased morbidity and resource utilization.

Renal disease is a common complication experienced by patients with sickle cell disease (SCD), though the epidemiology of acute kidney injury (AKI) in paediatric patients and its impact on long-term renal outcomes is unclear. We utilized the Pediatric Health Information System (PHIS) to identify inpatient encounters of paediatric patients with SCD admitted for vaso-occlusive pain crisis (VOC). Overall, 1·4% of patients experienced at least one episode of AKI and 2·5% of admissions were complicated by AKI. Patients with at least one episode of AKI were more likely to be adolescents or young adults at the time of their initial admission, had increased rates of admission to the ICU, longer lengths of stay, increased costs of hospitalization, increased risk of readmission and increased rates of SCD-related comorbidities. Generalized estimating equation modelling demonstrated that increasing age, history of hypertension, history of haematuria and history of chronic kidney disease were associated with increased odds of developing AKI, though hydroxycarbamide use (OR 0·64, 95% CI 0·44-0·94) was protective. Episodes of AKI during hospitalization in children with SCD are associated with increased morbidity and utilization of hospital resources. Increasing the use of hydroxycarbamide may decrease the likelihood of this complication.

Evaluating Pediatric Sepsis Definitions Designed for Electronic Health Record Extraction and Multicenter Quality Improvement.

OBJECTIVES: To describe the Children's Hospital Association's Improving Pediatric Sepsis Outcomes sepsis definitions and the identified patients; evaluate the definition using a published framework for evaluating sepsis definitions. DESIGN: Observational cohort. SETTING: Multicenter quality improvement collaborative of 46 hospitals from January 2017 to December 2018, excluding neonatal ICUs. PATIENTS: Improving Pediatric Sepsis Outcomes Sepsis was defined by electronic health record evidence of suspected infection and sepsis treatment or organ dysfunction. A more severely ill subgroup, Improving Pediatric Sepsis Outcomes Critical Sepsis, was defined, approximating septic shock. INTERVENTIONS: Participating hospitals identified patients, extracted data, and transferred de-identified data to a central data warehouse. The definitions were evaluated across domains of reliability, content validity, construct validity, criterion validity, measurement burden, and timeliness. MEASUREMENTS AND MAIN RESULTS: Forty hospitals met data quality criteria across four electronic health record platforms. There were 23,976 cases of Improving Pediatric Sepsis Outcomes Sepsis, including 8,565 with Improving Pediatric Sepsis Outcomes Critical Sepsis. The median age was 5.9 years. There were 10,316 (43.0%) immunosuppressed or immunocompromised patients, 4,135 (20.3%) with central lines, and 2,352 (11.6%) chronically ventilated. Among Improving Pediatric Sepsis Outcomes Sepsis patients, 60.8% were admitted to intensive care, 26.4% had new positive-pressure ventilation, and 19.7% received vasopressors. Median hospital length of stay was 6.0 days (3.0-13.0 d). All-cause 30-day in-hospital mortality was 958 (4.0%) in Improving Pediatric Sepsis Outcomes Sepsis; 541 (6.3%) in Improving Pediatric Sepsis Outcomes Critical Sepsis. The Improving Pediatric Sepsis Outcomes Sepsis definitions demonstrated strengths in content validity, convergent construct validity, and criterion validity; weakness in reliability. Improving Pediatric Sepsis Outcomes Sepsis definitions had significant initial measurement burden (median time from case completion to submission: 15 mo [interquartile range, 13-18 mo]); timeliness improved once data capture was established (median, 26 d; interquartile range, 23-56 d). CONCLUSIONS: The Improving Pediatric Sepsis Outcomes Sepsis definitions demonstrated feasibility for large-scale data abstraction. The patients identified provide important information about children treated for sepsis. When operationalized, these definitions enabled multicenter identification and data aggregation, indicating practical utility for quality improvement.

Mucosal barrier injury-associated bloodstream infections in pediatric oncology patients.

BACKGROUND: Single-center reports of central line-associated bloodstream infection (CLABSI) and the subcategory of mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) in pediatric hematology oncology transplant (PHO) patients have focused on the inpatient setting. Characterization of MBI-LCBI across PHO centers and management settings (inpatient and ambulatory) is urgently needed to inform surveillance and prevention strategies. METHODS: Prospectively collected data from August 1, 2013, to December 31, 2015, on CLABSI (including MBI-LCBI) from a US PHO multicenter quality improvement network database was analyzed. CDC National Healthcare Safety Network definitions were applied for inpatient events and adapted for ambulatory events. RESULTS: Thirty-five PHO centers reported 401 ambulatory and 416 inpatient MBI-LCBI events. Ambulatory and inpatient MBI-LCBI rates were 0.085 and 1.01 per 1000 line days, respectively. Fifty-three percent of inpatient CLABSIs were MBI-LCBIs versus 32% in the ambulatory setting (P  <  0.01). Neutropenia was the most common criterion defining MBI-LCBI in both settings, being present in ≥90% of events. The most common organisms isolated in MBI-LCBI events were Escherichia coli (in 28% of events), Klebsiella spp. (23%), and viridans streptococci (12%) in the ambulatory setting and viridans streptococci (in 29% of events), E. coli (14%), and Klebsiella spp. (14%) in the inpatient setting. CONCLUSION: In this largest study of PHO MBI-LCBI inpatient events and the first such study in the ambulatory setting, the burden of MBI-LCBI across the continuum of care of PHO patients was substantial. These data should raise awareness of MBI-LCBI among healthcare providers for PHO patients, help benchmarking across centers, and help inform prevention and treatment strategies.