Alison Riese

Effect of a Hospital-wide High-Flow Nasal Cannula Protocol on Clinical Outcomes and Resource Utilization of Bronchiolitis Patients Admitted to the PICU.

OBJECTIVE To assess the association of the introduction of a high-flow nasal cannula (HFNC) protocol with clinical outcomes and hospital charges of infants with bronchiolitis initially admitted to the PICU. METHODS We conducted a retrospective, nonrandomized, preintervention-postintervention study of infants with bronchiolitis initially admitted to the PICU for HFNC. We compared patients admitted in the 24 months before and after protocol initiation for HFNC use on the general wards. The primary outcome assessed was length of hospital stay (LOS), and the secondary outcomes included total hospital charges, intubation, and 30-day readmission. We conducted bivariate analysis using χ² test for categorical variables and Students t test or Wilcoxon rank sum test for continuous variables. RESULTS Two hundred and ninety patients were admitted to the PICU on HFNC; 120 patients were admitted before and 170 admitted after the introduction of HFNC use on the general wards. Comparing the 2 groups, the median LOS was significantly reduced (4 days vs 3 days; P < .001), as was the median total hospital charges (

Clinical Outcomes of Bronchiolitis After Implementation of a General Ward High Flow Nasal Cannula Guideline

12 257 vs

Clinical Performance Evaluations of Third-Year Medical Students and Association With Student and Evaluator Gender.

9337; P < .001). After starting HFNC use on the wards, 30% of patients initially admitted to the PICU were ultimately transferred to the wards while still on HFNC. There was no difference in intubation rate or 30-day readmission between the 2 groups. CONCLUSIONS For bronchiolitis patients initially admitted to the PICU, initiating a guideline for HFNC use on the general pediatric wards is associated with reduced total hospital LOS and total hospital charges, with no difference in intubation rates or 30-day readmission.

Prompting Discussions of Youth Violence Using Electronic Previsit Questionnaires in Primary Care: A Cluster Randomized Trial

OBJECTIVE The goal of this study was to assess the association of the introduction of a wards high-flow nasal cannula (HFNC) guideline with clinical outcomes of infants with bronchiolitis. METHODS We conducted a retrospective, pre-post intervention study with an interrupted time series analysis of infants admitted with bronchiolitis between 2010 and 2014 at an urban, tertiary care childrens hospital. Patients admitted in the 24 months before and after initiation of a guideline for HFNC use on the general wards were compared. The primary outcome was length of hospital stay. Secondary outcomes were PICU transfer rate and length of stay, intubation rate, and 30-day readmission, adjusted for season. RESULTS A total of 1937 patients met inclusion criteria; 936 were admitted before and 1001 admitted after the introduction of HFNC use on the general wards. Comparing the 2 groups, the hospital-wide rate of HFNC use in bronchiolitis treatment increased after HFNC became available on the wards (23.9% vs 35.2%; P < .001). The wards HFNC guideline was not associated with a change in preintervention trajectory of total hospital length of stay (P = .48), PICU length of stay (P = .06), or rate of PICU transfer (P = .97). There was also no difference in intubation rate or 30-day readmission between the 2 groups. CONCLUSIONS Initiating a guideline for HFNC use on the general pediatric wards was associated with an increase in the use of the intervention with no significant change in total hospital length of stay, PICU length of stay and transfer rate, intubation rate, or 30-day readmission for patients with bronchiolitis.

Documentation of Sexual History in Hospitalized Adolescents on the General Pediatrics Service

Purpose Clinical performance evaluations are major components of medical school clerkship grades. But are they sufficiently objective? This study aimed to determine whether student and evaluator gender is associated with assessment of overall clinical performance. Method This was a retrospective analysis of 4,272 core clerkship clinical performance evaluations by 829 evaluators of 155 third-year students, within the Alpert Medical School grading database for the 2013–2014 academic year. Overall clinical performance, assessed on a three-point scale (meets expectations, above expectations, exceptional), was extracted from each evaluation, as well as evaluator gender, age, training level, department, student gender and age, and length of observation time. Hierarchical ordinal regression modeling was conducted to account for clustering of evaluations. Results Female students were more likely to receive a better grade than males (adjusted odds ratio [AOR] 1.30, 95% confidence interval [CI] 1.13–1.50), and female evaluators awarded lower grades than males (AOR 0.72, 95% CI 0.55–0.93), adjusting for department, observation time, and student and evaluator age. The interaction between student and evaluator gender was significant (P = .03), with female evaluators assigning higher grades to female students, while male evaluators’ grading did not differ by student gender. Students who spent a short time with evaluators were also more likely to get a lower grade. Conclusions A one-year examination of all third-year clerkship clinical performance evaluations at a single institution revealed that male and female evaluators rated male and female students differently, even when accounting for other measured variables.

A survey of resident attitudes and behaviors regarding youth violence prevention in the acute care setting.

OBJECTIVE Youth violence (YV) screening during primary care visits is not routinely performed. Electronic previsit questionnaires (PVQs) are viewed favorably by adolescents and can prompt disclosure and discussion of sensitive health topics. This study aimed to determine the efficacy of an electronic PVQ in prompting YV discussions. METHODS A 4-month cluster-randomized controlled trial was conducted in a large urban academic primary care clinic. The clinics 4 practice groups were randomized to intervention or control assignment. A consecutive sample of adolescents aged 13 to 19 years presenting for annual visits were recruited. Participants completed an electronic PVQ (TickiT) either with (intervention) or without (control) YV questions. PVQ results were delivered to physicians before the visit. The frequency of YV discussions was measured using exit surveys of adolescents. Patients who reported YV discussion rated the helpfulness of the discussion. Multilevel mixed effect logistic regression was conducted to compare likelihood of YV discussion between intervention and control groups. RESULTS A total of 183 adolescents (90% of eligible) participated. Overall, 30% of adolescents reported some YV involvement. Sixty-five percent of the intervention group and 42% of the control group reported discussing YV during their visit. Thirty-one percent of adolescents in the intervention group who disclosed YV involvement reported not having a YV discussion. The intervention group had 2.6 (95% confidence interval 1.2-5.6) times the odds of discussing YV. Sixty-six percent of adolescents who discussed YV with their doctor rated the discussion as very helpful. CONCLUSIONS An electronic PVQ with items related to YV is acceptable and feasible, and it significantly improves frequency of patient-provider YV discussion.

Effects of a Web-based Educational Module on Pediatric Emergency Medicine Physicians’ Knowledge, Attitudes, and Behaviors Regarding Youth Violence

OBJECTIVES To determine the frequency of sexual history taking and the associated characteristics of hospitalized adolescents in the pediatric hospitalist service. METHODS A retrospective chart review of adolescents 14 to 18 years old who were admitted to the pediatric hospitalist service at an urban, academic childrens hospital in the Northeast from 2013 to 2015 was conducted. Repeat admissions, admissions to specialty services, and charts that noted impairment because of psychosis, cognitive delay, or illness severity were excluded. For charts that met the criteria, the admission history and physical was carefully reviewed for a notation of sexual history. For those with documentation, sexual activity status and a risk level assessment were recorded. Patient demographics and admission characteristics were extracted. χ2 tests and logistic regression were used to examine differences between those with sexual history and those without. RESULTS A total of 752 charts met the criteria for inclusion. The majority of adolescents were girls (n = 506; 67.3%); the mean age was 15.7 years (SD = 1.2). Girls had 2.99 (95% confidence interval [CI] 2.18-4.11) higher odds of documentation than boys, and older adolescents had 1.41 (95% CI 1.03-1.91) higher odds than younger adolescents. Documentation did not differ significantly on the basis of admission type (medical or psychiatric), admission time, patient race and/or ethnicity, or provider gender. Among those with a documented sexual history, risk-level details were often omitted. CONCLUSIONS Sexual history taking does not occur universally for hospitalized adolescents. Girls were screened more often than boys despite similar rates of sexual activity. The inpatient admission may be a missed opportunity for harm-reduction counseling and adherence to sexually transmitted infection testing guidelines.

Extracurricular Activities and Bullying Perpetration: Results From a Nationally Representative Sample

BACKGROUND Surgery, emergency medicine (EM), and pediatric resident physicians play an integral role in treating youth violence patients. We assessed these residents’ behaviors, attitudes, and perceived barriers to youth violence prevention (YVP) in the acute care setting. METHODS A cross-sectional survey of EM, surgery, and pediatric residents at one large medical institution was conducted using a theory-based self-administered paper questionnaire. Data were analyzed using descriptive statistics and Fisher’s exact tests to examine differences between resident specialties. RESULTS Of 73 residents, 55 completed the questionnaire, composed of 23 EM (42%), 18 pediatrics (33%), and 14 surgery (25%) residents, with a response rate of 75%. Fifteen percent (n = 8) of the respondents received YVP training during residency. The majority (n = 49, 91%.) of the respondents reported consistently collecting a history of events leading to violent injury. A smaller percentage of residents reported consistent assessment of retaliation risk (n = 11, 20%), referral to social work (n = 37, 69%), and screening for substance abuse (n = 37, 69%) and mental health (n = 35, 65%). Surgery residents were more likely than pediatric and EM residents to refer to social work (100% vs. 72% and 45%, p < 0.01) and screen for substance abuse (93% vs. 78% and 45%, p = 0.01). While the majority of residents agreed that youth violence is preventable (n = 50, 91%) and physicians should play a role in prevention (n = 47, 85%), there was less agreement that YVP should be a resident task (n = 38, 69%). Less than half of residents (n = 26, 47%) felt competent discussing safety risks and plans. Residents cited lack of time and training as the top two barriers for conducting risk assessments and referring to support services. CONCLUSION While EM, surgery, and pediatric residents agree that YVP is essential and should involve physicians, many do not perceive this as part of their responsibilities, and they do not feel competent in this role. LEVEL OF EVIDENCE Epidemiologic study, level III.