Allison Kempe

Association Between Early Lactate Levels and 30-Day Mortality in Clinically Suspected Sepsis in Children.

Importance Improving emergency care of pediatric sepsis is a public health priority, but optimal early diagnostic approaches are unclear. Measurement of lactate levels is associated with improved outcomes in adult septic shock, but pediatric guidelines do not endorse its use, in part because the association between early lactate levels and mortality is unknown in pediatric sepsis. Objective To determine whether the initial serum lactate level is associated with 30-day mortality in children with suspected sepsis. Design, Setting, and Participants This observational cohort study of a clinical registry of pediatric patients with suspected sepsis in the emergency department of a tertiary children’s hospital from April 1, 2012, to December 31, 2015, tested the hypothesis that a serum lactate level of greater than 36 mg/dL is associated with increased mortality compared with a serum lactate level of 36 mg/dL or less. Consecutive patients with sepsis were identified and included in the registry following consensus guidelines for clinical recognition (infection and decreased mental status or perfusion). Among 2520 registry visits, 1221 were excluded for transfer from another medical center, no measurement of lactate levels, and patients younger than 61 days or 18 years or older, leaving 1299 visits available for analysis. Lactate testing is prepopulated in the institutional sepsis order set but may be canceled at clinical discretion. Exposures Venous lactate level of greater than 36 mg/dL on the first measurement within the first 8 hours after arrival. Main Outcomes and Measures Thirty-day in-hospital mortality was the primary outcome. Odds ratios were calculated using logistic regression to account for potential confounders. Results Of the 1299 patients included in the analysis (753 boys [58.0%] and 546 girls [42.0%]; mean [SD] age, 7.3 [5.3] years), 899 (69.2%) had chronic medical conditions and 367 (28.3%) had acute organ dysfunction. Thirty-day mortality occurred in 5 of 103 patients (4.8%) with lactate levels greater than 36 mg/dL and 20 of 1196 patients (1.7%) with lactate levels of 36 mg/dL or less. Initial lactate levels of greater than 36 mg/dL were significantly associated with 30-day mortality in unadjusted (odds ratio, 3.00; 95% CI, 1.10-8.17) and adjusted (odds ratio, 3.26; 95% CI, 1.16- 9.16) analyses. The sensitivity of lactate levels greater than 36 mg/dL for 30-day mortality was 20.0% (95% CI, 8.9%-39.1%), and specificity was 92.3% (90.7%-93.7%). Conclusions and Relevance In children treated for sepsis in the emergency department, lactate levels greater than 36 mg/dL were associated with mortality but had a low sensitivity. Measurement of lactate levels may have utility in early risk stratification of pediatric sepsis.

School-Located Influenza Vaccination With Third-Party Billing: Outcomes, Cost, and Reimbursement

OBJECTIVE To assess rates of immunization; costs of conducting clinics; and reimbursements for a school-located influenza vaccination (SLIV) program that billed third-party payers. METHODS SLIV clinics were conducted in 19 elementary schools in the Denver Public School district (September 2010 to February 2011). School personnel obtained parental consent, and a community vaccinator conducted clinics and performed billing. Vaccines For Children vaccine was available for eligible students. Parents were not billed for any fees. Data were collected regarding implementation costs and vaccine cost was calculated using published private sector prices. Reimbursement amounts were compared to costs. RESULTS Overall, 30% of students (2784 of 9295) received ≥1 influenza vaccine; 39% (1079 of 2784) needed 2 doses and 80% received both. Excluding vaccine costs, implementation costs were

Effectiveness of primary care-public health collaborations in the delivery of influenza vaccine: a cluster-randomized pragmatic trial.

24.69 per vaccination. The percentage of vaccine costs reimbursed was 62% overall (82% from State Child Health Insurance Program (SCHIP), 50% from private insurance). The percentage of implementation costs reimbursed was 19% overall (23% from private, 27% from Medicaid, 29% from SCHIP and 0% among uninsured). Overall, 25% of total costs (implementation plus vaccine) were reimbursed. CONCLUSIONS A SLIV program resulted in vaccination of nearly one third of elementary students. Reimbursement rates were limited by 1) school restrictions on charging parents fees, 2) low payments for vaccine administration from public payers and 3) high rates of denials from private insurers. Some of these problems might be reduced by provisions in the Affordable Care Act.

The depth, duration, and degree of outpatient pediatric polypharmacy in Colorado fee-for-service Medicaid patients†

OBJECTIVE To assess effectiveness and feasibility of public-private collaboration in delivering influenza immunization to children. METHODS Four pediatric and four family medicine (FM) practices in Colorado with a common public health department (PHD) were randomized at the beginning of baseline year (10/2009) to Intervention (joint community clinics and PHD nurses aiding in delivery at practices); or control involving usual care without PHD. Generalized estimating equations compared changes in rates over baseline between intervention and control practices at end of 2nd intervention year (Y2=5/2011). Barriers to collaboration were examined using qualitative methods. RESULTS Overall, rates increased from baseline to Y2 by 9.2% in intervention and 3.2% in control (p<.0001), with significant increases in both pediatric and FM practices. The largest increases were seen among school-aged and adolescent children (p<.0001 for both), with differences for 6-month-old to 5-year-old children and for children with high-risk conditions not reaching significance. Barriers to collaboration included uncertainty regarding the delivery of vaccine supplies, concerns about using up all purchased vaccine by practices, and concerns about documentation of vaccination if collaboration occurred. CONCLUSIONS In spite of barriers, public-private collaboration resulted in significantly higher influenza immunization rates, particularly for older, healthy children who visit providers less frequently.

Adolescents’ Perspectives on Vaccination Outside the Traditional Medical Home A Survey of Urban Middle and High School Students

Outpatient pediatric polypharmacy is poorly characterized. Identification of at‐risk populations has clinical implications for pharmacy case management programs. We described the degree of exposure to polypharmacy using parameters of depth (concurrent medication count) and duration, reported commonly dispensed medications and exposure to three example potential drug–drug interactions by different depths of polypharmacy, and determined patient characteristics associated with exposure to increased degrees (a function of depth and duration) of polypharmacy.

Reducing the Underimmunization of Transplant Recipients

Eleventh- and 6th-grade students from an urban public school district were surveyed concerning vaccination outside the traditional medical home. Survey response rates were 50% for 11th- and 73% for 6th-grade students. Seventy-two percent of 11th-grade students reported that public health clinics were definitely or probably acceptable locations for vaccination; 70% reported this for emergency departments, 65% for school-based health centers, 55% for family planning clinics, and 44% for obstetrics/gynecology clinics. Corresponding percentages for 6th-grade students were 60% for public health clinics, 49% for emergency departments, 39% for school-based health centers, and 36% for family planning clinics. Sixth-grade students were not asked about obstetrics/gynecology clinics. Forty-seven percent of respondents identified a doctor’s office as the “best” setting to receive vaccines, more than identified any other setting. We concluded that vaccination in one or more settings outside the traditional medical home was acceptable to most adolescents.

Pediatric hospitalist comanagement of spinal fusion surgery patients.

Vaccine-preventable infections (VPIs) are a common and serious complication after pediatric liver transplantation; in the first 2 years after transplant, 1 of 6 transplant recipients requires hospitalization for VPI, which is associated with graft injury, morbidity, and sometimes mortality.1 These hospitalizations can increase the cost of the transplant-associated hospitalization by

School-Located Influenza Vaccination With Third-Party Billing: What Do Parents Think?

70 000.1 Although the increased risk for infection owing to immunosuppression after transplant is partially to blame, a primary factor responsible for this statistic is that transplant candidates receive significantly fewer immunizations than do healthy children. Although children with organ failure receive constant medical surveillance, many are not fully vaccinated at the time of transplant despite the known importance of pretransplant vaccination (before a child becomes immunosuppressed and has attenuated antibody responses) and recommendations of the Infectious Diseases Society of America that “all solid organ transplant candidates receive age-appropriate vaccines based on the CDC [Centers for Disease Control and Prevention] schedule.”2,p37 Compared with the 90% reported immunization rate among children entering kindergarten in the United States,3 the majority of pediatric transplant recipients are not up to date on immunizations at the time of transplant (even when excluding those receiving transplants for acute organ failure).4 Because of the adverse outcomes that VPIs have on pediatric transplant recipients and the US investment of

Paediatric spinal fusion surgery and the transition to home‐based care: provider expectations and carer experiences

200 million dollars every year in pediatric liver transplants, we should do better. The situation is more urgent because of the increase nationally over the past 20 years of nonmedical exemptions for school immunizations.5 The resurgence of VPIs is of concern to many individuals but especially to transplant recipients. To address this situation, we must pursue a 2-pronged approach involving policy and enhanced practice methods, taking both a stronger stance on requiring immunizations for pediatric transplant candidates and on improving coordination and tracking of vaccine administration to these patients. US policy should require complete immunization for nonemergent transplants. Currently, individual transplant centers are left to construct their own immunization policies. Transplant organizations, such as the United Network for Organ Sharing, should develop policies that require complete, appropriate-for-age immunization status at the time of a nonemergent transplant. Promoting a vaccine mandate for the pediatric transplant population would advance several important clinical and ethical goals. First, complete immunization would ensure the child’s best interest by minimizing harms. All transplant recipients are administered immunosuppressive medications to prevent graft rejection and thus are susceptible to infection. Parental refusal to immunize a child leaves that immunocompromised child unprotected against various undesired outcomes. VPIs have been associated with allograft rejection, encephalitis, meningitis, pneumonitis, and death after transplant.1,6 When a parent’s choice is contrary to the best interests of the child and places the child at risk of significant harm,7 the state has the authority to intervene to protect the child and has done so to allow children to receive life-saving therapies, such as blood transfusions or chemotherapy. Vaccines are potentially lifesaving for an immunocompromised transplant recipient and should be treated as such. Second, complete immunization of one pediatric transplant recipient protects other pediatric transplant recipients through herd immunity, whereby vaccination of a significant portion of the population provides some protection for individuals who have not or cannot develop immunity. Herd immunity is particularly important in the transplant population because certain transplant candidates and recipients cannot receive vaccines (for example, live vaccines are not administered before transplant when transplant is anticipated to occur in <30 days and are not administered after transplant unless the child is receiving low levels of immunosuppressive treatment). Therefore, underimmunization of a transplant recipient poses a danger to that recipient, immunocompromised members of the transplant community, and other iatrogenically or natively immunocompromised individuals. Of note, even when a transplant candidate does not mount a protective antibody response to pretransplant immunizations, they are more likely than previously unimmunized children to mount a good response to posttransplant immunizations.8 Third, requiring complete immunization promotes a more just allocation of a scarce resource. Despite advances in technology and efforts to increase organ donation awareness, there continues to be a large difference between organ supply and demand. Every day, 22 individuals die while awaiting an organ transplant. If a child develops a VPI, that infection has the potential to result in graft failure or death. Loss of the organ harms not only that child but also everyone who died on the waiting list because no organ was available. Policies to promote complete immunization must be paired with a better practice system to coordinate the immunization of these at-risk children. In the pretransplant period, subspecialists must partner with infectious diseases physicians and primary care VIEWPOINT