Arpi Bekmezian

Persistence of myosin heavy chain-based fiber types in innervated but silenced rat fast muscle

Myosin heavy chain (MHC) profile and size of fibers in deep and superficial regions of the adult rat medial gastrocnemius (MG) were determined after 4, 15, 30, and 60 days of inactivity induced by spinal cord isolation (SI). After 4 days, fiber size decreased by 33 to 50% and 36 to 46% in deep and superficial regions, whereas MHC composition was unaffected. By 15 days, these values were 45 to 78% and 51 to 69%, and MHC composition was shifting toward faster isoforms. By 60 days, there were no pure type I MHC fibers and increases from 1 to 18% and 78 to 93% in pure type IIb fibers in deep and superficial regions. The percentage of type I MHC (gel electrophoresis) was∼10 and ∼3%, and of type IIb ∼40 and ∼60% in control and 60‐day SI rats. Thus, adaptations in the MHC molecule occurred at a slower rate and for a longer duration than the atrophic response.

Staff-Only Pediatric Hospitalist Care of Patients With Medically Complex Subspecialty Conditions in a Major Teaching Hospital

OBJECTIVE To assess cost and length of stay for subspecialty patients on a staff-only general pediatric hospitalist service vs traditional faculty/housestaff subspecialty services in a major teaching hospital. DESIGN Retrospective study of 2 cohort groups: a staff-only general pediatric hospitalist group and subspecialty faculty/housestaff gastroenterology and hematology/oncology groups. SETTING Major referral center providing full-spectrum, complex surgical, and subspecialty care including transplantation. PARTICIPANTS Nine hundred twenty-five pediatric patients with gastroenterologic and hematologic/oncologic diseases admitted and discharged between July 1, 2005, and June 30, 2006. Main Exposure Patients with gastroenterologic and hematologic/oncologic diseases were assigned to the hospitalist team when faculty/housestaff teams reached their maximum census of patients per intern. MAIN OUTCOME MEASURES Cost, length of stay, mortality, and readmission to the hospital within 72 hours of discharge. RESULTS Cost averaged

Factors Associated with Prolonged Emergency Department Length of Stay for Admitted Children

11 000 and

Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions

16 500, respectively, for patients on the hospitalist service compared with those on nonhospitalist services. On average, length of stay was 7.2 days and 9.8 days, respectively. In negative binomial regression analyses controlling for subspecialty, demographic data, disease severity, and average daily census, patients on the hospitalist service had 29% lower costs (P < .05) and 38% fewer hospital days (P < .01) per admission compared with patients on subspecialty faculty/housestaff services, with no clear differences in mortality and readmission rates. CONCLUSION Compared with the subspecialist faculty/housestaff system, the staff-only pediatric hospitalist system was associated with a marked reduction in cost and length of stay for patients with medically complex subspecialty diseases. In this era of resident duty-hour restrictions and medical complexity of conditions in inpatients, staff-only hospitalist programs may have a vital role in pediatric teaching hospitals.

Pediatric Emergency Departments are More Likely Than General Emergency Departments to Treat Asthma Exacerbation With Systemic Corticosteroids

Objective: To estimate the prevalence of and to identify factors associated with prolonged emergency department length-of-stay (ED-LOS) for admitted children. Methods: Data were from the 2001-2006 National Hospital Ambulatory Medical Care Survey. The primary outcome was prolonged ED-LOS (defined as total ED time >8 hours) among admitted children. Predictor variables included patient-level (eg, demographics including race/ethnicity, triage score, diagnosis, and admission to inpatient bed vs intensive care unit), physician-level (intern/resident vs attending physician), and system-level (eg, region, metropolitan area, ED and hospital type, time and season, and diagnostic and therapeutic procedures) factors. Multivariable logistic regression was performed to identify independent predictors of prolonged ED-LOS. Results: Median ED-LOS for admitted children was 3.7 hours. Thirteen percent of pediatric patients admitted from the ED experienced prolonged ED-LOS. Factors associated with prolonged ED-LOS for admitted children were Hispanic ethnicity (odds ratio [OR], 1.76; 95% confidence interval [95% CI], 1.10-2.81), ED arrival between midnight and 8 a.m. (OR, 2.80; 95% CI, 1.87-4.20), winter season (January-March: OR, 1.81; 95% CI, 1.20-2.74), computed tomography scan or magnetic resonance imaging (OR, 1.65; 95% CI, 1.05-2.58), and intravenous fluids or medications (OR, 1.81; 95% CI, 1.10-2.97). Children requiring ICU admissions (OR, 0.29; 95% CI, 0.11-0.77) or receiving pulse oximetry in the ED (OR, 0.52; 95% CI, 0.34-0.81) had a lower risk of experiencing prolonged ED-LOS. Conclusions: We found that prolonged ED-LOS occurs frequently for admitted pediatric patients and is associated with Hispanic ethnicity, presentation during winter season, and early morning arrival. Potential strategies to reduce ED-LOS include improved availability of interpreter services and enhanced staffing and additional inpatient bed availability during winter season and overnight hours.

Research Needs of Pediatric Hospitalists

Abstract Objective: Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED. Methods: A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared. Results: A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45 min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1 h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received > 1 bronchodilator dose within 1 h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76). Conclusion: A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.

Standardized admission order set improves perceived quality of pediatric inpatient care

Objective. To determine whether systemic corticosteroids are under-prescribed (as measured by current NIH treatment guidelines) for children in the United States seen in the emergency department (ED) for acute asthma, and to identify factors associated with prescribing systemic corticosteroids. Methods. We used data from the 2001–2007 National Hospital Ambulatory Medical Care Survey. The study population was children ≤18 years old in the ED with a primary diagnosis of asthma (ICD-9-CM code 493.xx) who received bronchodilator(s). The primary outcome was receipt of a systemic corticosteroid in the ED. Independent variables included patient-level (e.g., demographics, insurance, fever, admission), physician-level (provider type, ancillary medications and tests ordered), and system-level factors (e.g., ED type, geographic location, time of day, season, year). We used multivariable logistic regression techniques to identify factors associated with systemic corticosteroid treatment. Results. Systemic corticosteroids were prescribed at only 63% of pediatric acute asthma visits to EDs. Over the study period, there was a trend toward increasing systemic corticosteroid use (p for trend = .05). After adjusting for potential confounders, patients were more likely to receive systemic corticosteroids when treated in pediatric EDs than in general EDs (OR = 2.45; 95% CI: 1.26–4.77).Conclusion. Systemic corticosteroids are under-prescribed for children who present to EDs with acute asthma exacerbations. Pediatric EDs are more likely than general EDs to treat asthma exacerbations with systemic corticosteroids. Differences in the process of care in pediatric ED settings (compared to general EDs) may increase the likelihood of adherence to NIH treatment guidelines.

Emergency department crowding and younger age are associated with delayed corticosteroid administration to children with acute asthma.

OBJECTIVE To assess the current state of research productivity, goals, obstacles, and needs of pediatric hospitalists. METHODS The American Academy of Pediatrics Section on Hospital Medicine performed a cross-sectional online survey of pediatric hospitalists. Questions assessed demographics, research productivity, system-level factors, research interests, goals and obstacles, and the perceived need for research training and support. RESULTS Two hundred twenty pediatric hospitalists in the United States completed the survey. Of these, 56% had presented at a national meeting, 24% were first authors of an article in a peer-reviewed journal, 8% had more than publications, and 12% had secured external grant support. While 90% of respondents had spent 10% or less time in research, 64% had an academic appointment at the assistant professor level or above. Nearly 40% felt that their institution expected them to do research, and 56% were interested and another 27% were very interested in conducting research. The main research interest was quality improvement (QI) evaluation. Common obstacles to research were lack of time, mentorship, and resources. CONCLUSIONS Pediatric hospitalists want to conduct research to improve the quality of inpatient care but face significant obstacles including lack of dedicated time for research and mentorship. Coordinated efforts to improve access to academic resources are important for career development and academic growth of the field. National organizations and hospital programs interested in improving the quality of care for hospitalized children can provide support to meet the fields professional needs for research.

Boarding admitted children in the emergency department impacts inpatient outcomes.

BACKGROUND Few studies exist on the ability of standardized preprinted order forms to improve patient care. OBJECTIVE To examine resident-perceived effects of introducing a pediatric admission order set (PAOS) on the quality of inpatient care. DESIGN Cross-sectional study. SETTING University of California, Los Angeles (UCLA) Childrens Hospital, a nonprofit, tertiary-care teaching hospital and major referral center with approximately 3,000 admissions per year. PARTICIPANTS A total of 97 pediatric residents (PL-1, n=34; PL-2, n=33; and PL-3, n=30) who did the vast majority of the inpatient admissions. MEASUREMENTS Residents were asked to rate the PAOS overall and with respect to 9 specific dimensions using a 5-point Likert scale. RESULTS Overall, 89% of respondents approved of the PAOS, 58% reported using it >or= 90% of the time, and all said that they would recommend it to their colleagues. Eighty-four percent thought that it improved inpatient care, and 75% thought that medical errors were reduced. Eighty-eight percent reported that the PAOS saved time; 93% said it was convenient; and most reported less need for clarification with secretaries (81%) and nurses (82%). In multivariate regression analyses, the only predictor of overall rating was whether the PAOS improved inpatient care (P=0.04). Improved patient care, meanwhile, was predicted by whether the PAOS was comprehensive (P=0.01), reduced medical errors (P=0.01), and required less clarification with nurses (P=0.01). CONCLUSIONS A standardized admission order set is a simple, low-cost intervention that residents believe may benefit patients by reducing medical errors and expediting high-quality care.

Rising Utilization of Inpatient Pediatric Asthma Pathways.

Objective This study aimed to identify factors associated with delayed or omission of indicated steroids for children seen in the emergency department (ED) for moderate-to-severe asthma exacerbation. Methods This was a retrospective study of pediatric (age ⩽ 21 years) patients treated in a general academic ED from January 2006 to September 2011 with a primary diagnosis of asthma (International Classification of Diseases, Ninth Revision code 493.xx) and moderate-to-severe exacerbations. A moderate-to-severe exacerbation was defined as requiring 2 or more (or continuous) bronchodilators. We determined the proportion of visits in which steroids were inappropriately omitted or delayed (>1 hour from arrival). Multivariable logistic regression models were used to identify patient, physician, and system factors associated with delayed or omitted steroids. Results Of 1333 pediatric asthma ED visits, 817 were for moderate-to-severe exacerbation; 645 (79%) received steroids. Patients younger than 6 years (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.19–4.24), requiring more bronchodilators (OR, 2.82; 95% CI, 2.10–3.79), initially hypoxic (OR, 2.78; 95% CI, 1.33–5.83), or tachypneic (OR, 1.52; 95% CI, 1.05–2.20) were more likely to receive steroids. Median time to steroid administration was 108 minutes (interquartile range, 65–164 minutes). Steroid administration was delayed in 502 visits (78%). Patients with hypoxia (OR, 1.91; 95% CI, 1.11–3.27) or tachypnea (OR, 1.82; 95% CI, 1.17–2.84) were more likely to receive steroids 1 hour or less of arrival, whereas children younger than 2 years (OR, 0.16; 95% CI, 0.07–0.35) and those arriving during periods of higher ED volume (OR, 0.79; 95% CI, 0.67–0.94) were less likely to receive timely steroids. Conclusions In this ED, steroids were underprescribed and frequently delayed for pediatric ED patients with moderate-to-severe asthma exacerbation. Greater ED volume and younger age are associated with delays. Interventions are needed to expedite steroid administration, improving adherence to National Institutes of Health asthma guidelines.