Aileen P. Schast

Perceived barriers to adherence among adolescent renal transplant candidates.

Abstract:  Non‐adherence to medical regimens is a ubiquitous hindrance to quality health care among adolescent transplant recipients. Identification of potentially modifiable barriers to adherence when patients are listed for organ transplant would help with early intervention efforts to prepare adolescents for the stringent medication regimen post‐transplant. Fifty‐six adolescents listed for a kidney transplant, mean age 14.27 (s.d. = 2.2; range 11–18 yr), 73.2% male, 62.5% Caucasian participated in a semi‐structured interview, the Medical Adherence Measure, to assesses the patient’s knowledge of the prescribed regimen, reported adherence (missed and late doses), the system used to organized medications, and who holds the primary responsibility over medication management. Better knowledge of the medication regimen was associated with fewer missed doses (r = −0.48, p < 0.001). Patients who perceived more barriers had more missed (r = 0.38, p = 0.004) and late (r = 0.47, p < 0.001) doses. Patients who endorsed “just forget,” the most common barrier (56.4%), reported significantly more missed (z = −4.25, p < 0.001) and late (z = −2.2, p = 0.02) doses. Only one‐third of the transplant candidates used a pillbox to organize medications but these patients had significantly better adherence, z = −2.2, p = 0.03. With regard to responsibility over managing the regimens, adolescents missed fewer doses when their parents were in charge than when they were solely responsible, z = −2.1, p = 0.04. Interventions developed to prepare transplant candidates for a stringent post‐transplant regimen need to focus on ensuring accurate knowledge of as simple a regimen as possible. Use of an organized system such as a pillbox to establish a routine and facilitate tracking of medications is recommended with integration of reminders that may be appealing for this age group. Although individuation is developmentally normative at this age, parent involvement seems critical until the adolescent is able to manage the responsibility more independently.

Quantifying demographic, urological and behavioral characteristics of children with lower urinary tract symptoms.

OBJECTIVE This project examines the voiding and behavioral characteristics of children referred to a specialty voiding clinic, including the impact of incontinence on the child and family. PATIENTS AND METHODS A total of 351 new patients (aged 5-17 years) referred to our specialty voiding clinic completed background information, including demographics and medical history, a standardized voiding questionnaire, school history, and questions about child and family quality of life, prior to their first appointment. RESULTS Patients are primarily female (53%) and Caucasian (70%) with a mean age of 9.5 years (range 5-17; SD=3.5). Of the patients, 25% were diagnosed with a mental or behavioral health problem. Mean urological symptom score was 12 (range 0-29). Higher symptom scores are associated with younger age, ethnic minority status, a mental health diagnosis, being on psychotropic medications, and a poor child and family quality of life. Families of children who are wet day and night reported a poorer quality of life as compared to the families of children who were daytime wetters or bedwetters only. CONCLUSION Symptom scores are associated with type of incontinence, social and quality of life variables. Collecting this baseline data will enable ongoing monitoring of progress for these complex patients.

Parent Stress and Coping: Waiting for a Child to Receive a Kidney Transplant

The current study examined the degree of parent stress and depression among mothers and fathers of children with end-stage renal disease (ESRD) listed for a kidney transplant, to determine whether demographic factors, stress, and coping would predict parent depression. Eighty-six mothers and 58 fathers of children with ESRD preparing for a kidney transplant completed standardized measures of parent stress related to the child’s chronic illness (PIP), coping style (Brief Cope), and depression (BDI-II). Information about the disease was obtained from the medical record. Maternal depression was predicted by having a lower family income, higher degree of parent stress associated with the child’s illness, and the use of avoidant coping strategies. Paternal depression was only predicted by higher parent stress. Illness related variables did not contribute significantly to the understanding of parent outcomes. Pre-transplant evaluations should screen for elevated levels of stress and depression, and develop interventions to help parents cope with their child’s renal disease.

Two-Step Process for ED UTI Screening in Febrile Young Children: Reducing Catheterization Rates

BACKGROUND AND OBJECTIVES: Urinary tract infection (UTI) screening in febrile young children can be painful and time consuming. We implemented a screening protocol for UTI in a high-volume pediatric emergency department (ED) to reduce urethral catheterization, limiting catheterization to children with positive screens from urine bag specimens. METHODS: This quality-improvement initiative was implemented using 3 Plan-Do-Study-Act cycles, beginning with a small test of the proposed change in 1 ED area. To ensure appropriate patients received timely screening, care teams discussed patient risk factors and created patient-specific, appropriate procedures. The intervention was extended to the entire ED after providing education. Finally, visual cues were added into the electronic health record, and nursing scripts were developed to enlist family participation. A time-series design was used to study the impact of the 6-month intervention by using a p-chart to determine special cause variation. The primary outcome measure for the study was defined as the catheterization rate in febrile children ages 6 to 24 months. RESULTS: The ED reduced catheterization rates among febrile young children from 63% to <30% over a 6-month period with sustained results. More than 350 patients were spared catheterization without prolonging ED length of stay. Additionally, there was no change in the revisit rate or missed UTIs among those followed within the hospital’s network. CONCLUSIONS: A 2-step less-invasive process for screening febrile young children for UTI can be instituted in a high-volume ED without increasing length of stay or missing cases of UTI.

Improving Recognition of Pediatric Severe Sepsis in the Emergency Department: Contributions of a Vital Sign–Based Electronic Alert and Bedside Clinician Identification

Study objective Recognition of pediatric sepsis is a key clinical challenge. We evaluate the performance of a sepsis recognition process including an electronic sepsis alert and bedside assessment in a pediatric emergency department (ED). Methods This was a cohort study with quality improvement intervention in a pediatric ED. Exposure was a positive electronic sepsis alert, defined as elevated pulse rate or hypotension, concern for infection, and at least one of the following: abnormal capillary refill, abnormal mental status, or high‐risk condition. A positive electronic sepsis alert prompted team assessment or huddle to determine need for sepsis protocol. Clinicians could initiate team assessment or huddle according to clinical concern without positive electronic sepsis alert. Severe sepsis outcome defined as activation of the sepsis protocol in the ED or development of severe sepsis requiring ICU admission within 24 hours. Results There were 182,509 ED visits during the study period, with 86,037 before electronic sepsis alert implementation and 96,472 afterward, and 1,112 (1.2%) positive electronic sepsis alerts. Overall, 326 patients (0.3%) were treated for severe sepsis within 24 hours. Test characteristics of the electronic sepsis alert alone to detect severe sepsis were sensitivity 86.2% (95% confidence interval [CI] 82.0% to 89.5%), specificity 99.1% (95% CI 99.0% to 99.2%), positive predictive value 25.4% (95% CI 22.8% to 28.0%), and negative predictive value 100% (95% CI 99.9% to 100%). Inclusion of the clinician screen identified 43 additional electronic sepsis alert–negative children, with severe sepsis sensitivity 99.4% (95% CI 97.8% to 99.8%) and specificity 99.1% (95% CI 99.1% to 99.2%). Electronic sepsis alert implementation increased ED sepsis detection from 83% to 96%. Conclusion Electronic sepsis alert for severe sepsis demonstrated good sensitivity and high specificity. Addition of clinician identification of electronic sepsis alert–negative patients further improved sensitivity. Implementation of the electronic sepsis alert was associated with improved recognition of severe sepsis.

Renal Transplantation into a Diverted Urinary System—Is it Safe in Children?

PURPOSE Historically surgeons caring for children with urinary diversion for bladder outlet obstruction have routinely performed undiversion before renal transplantation. We hypothesized that patients undergoing transplantation into a diverted system would have outcomes similar to those undergoing transplantation into a normal bladder. We review the outcomes of patients with and without diversion undergoing kidney transplantation at our institution. MATERIALS AND METHODS We retrospectively studied a cohort of children undergoing renal transplant between 1993 and 2006. Patients whose etiology of end-stage renal disease was either obstructive uropathy or renal dysplasia were included. Patients with less than 5 years of followup were excluded from the analysis. Four groups were assembled, ie controls with renal dysplasia and no history of obstructive uropathy undergoing transplant (group 1), patients with obstructive uropathy not diverted at transplant (group 2), patients with obstructive uropathy diverted at transplant (group 3) and patients with obstructive uropathy augmented before transplant (group 4). The groups were compared for outcomes of frequency of urinary tract infection, renal graft function and graft loss. RESULTS Of the 80 subjects eligible based on diagnostic criteria 43 had completed 5 years of followup. There was no significant difference between groups based on age (p = 0.508), renal function as measured by glomerular filtration rate (p = 0.526) or creatinine (p = 0.612), or frequency of urinary tract infections (p = 0.083). Only 1 patient in the cohort suffered graft loss. CONCLUSIONS Based on frequency of urinary tract infection, renal function and graft loss 5 years after transplant, there appears to be no added risk to transplanting a kidney into a diverted system.

Standardizing Care Processes and Improving Quality Using Pathways and Continuous Quality Improvement

Opinion statementHealth care providers have an opportunity to improve the quality of care provided by reducing unnecessary variation. Current evidence and expert consensus can be used to develop a standardized mental model that can be used by all members of a clinical team. Process management and continuous quality improvement can be applied to measure process, health, and patient satisfaction outcomes. Clinical pathways represent one method to accomplish these goals. When combined with targeted education, electronic clinical decision support, and robust measurement, this methodology can help to create the dynamic learning health care system that will support the health of the next generation of our children.

Pediatric Psychology in Genitourinary Anomalies

Children with genitourinary anomalies are at risk for developmental and adjustment challenges. Pediatric psychologists can address the needs of these children within the urology clinic through focusing on assessment, intervention, and prevention of psychosocial problems associated with their urologic diagnosis. Care is optimized if surgeons and mental health providers work together to care for this challenging group of patients.

Building a Clinical Quality Improvement Program

Opinion statementPurpose of review This analysis describes the development of a robust quality improvement infrastructure at a large academic children’s hospital and explores the foundational components of the program, as well as the implementation of a combined top-down and bottom-up approach to quality improvement. Recent findings Quality improvement efforts have been proven to enhance quality and patient safety in the pediatric hospital setting. Successful improvement efforts require a commitment to quality improvement, a strong combination of clinical leadership and expertise, trained improvement staff, a developed and flexible data infrastructure, and an institutional improvement framework. A robust data infrastructure and the role of the QI team composed of clinical leads, data analysts, and improvement advisors are also explored. Summary Combining a pragmatic framework with the appropriate staff and data infrastructure can result in a powerful clinical quality improvement program.