Concettina Tolomeo

Predictors of Asthma-related Pediatric Emergency Department Visits and Hospitalizations

Objective. Asthma is a leading cause of emergency department visits and hospitalizations for children in the United States. As part of a larger study, the purpose of this analysis was to determine which variables were most effective at predicting subsequent pediatric asthma-related emergency department visits and hospitalizations. Methods. A retrospective, descriptive study was conducted. Subjects consisted of a convenience sample of 298 children admitted to a New England Childrens Hospital in 2006 with a primary diagnosis of asthma. Data from two hospital databases were collected for 12 months before and 12 months after the 2006 admission. Basic descriptive statistics were followed by chi-square tests to determine which variables were associated with emergency department visits and hospitalizations. Logistic regression analysis was used to determine which variables were significant predictors of asthma-related emergency department visits and hospitalizations. Results. Sixty-percent of all subjects were male. Ninety subjects experienced a total of 145 emergency department visits and 54 experienced a total of 70 hospitalizations. A previous emergency department visit was a significant predictor of both subsequent emergency department visits and subsequent hospitalizations. Age was also an independent risk factor for subsequent hospitalizations. In this sample, the risk of a hospitalization increased with each year increase in age. Conclusion. These findings support the importance of early identification of children with asthma so that appropriate asthma management can be instituted before an emergency department visit occurs. Furthermore, results suggest involving school-age and preadolescent children in the care of their asthma so that they can be equipped and encouraged to self-manage their own asthma.

Esmarch Closure of Laparotomy Incisions in Unstable Trauma Patients

Fascial closure after laparotomy may be time-consuming and extremely difficult, especially in the setting of massive bowel edema. In the trauma patient with deteriorating hemodynamic status, hypothermia, or worsening hypoxia, expeditious abdominal wall closure is essential to facilitate rapid transport to the intensive care unit for further stabilization. With the increasing utilization of the abbreviated laparotomy in unstable trauma patients, innovative techniques for speedy fascial closure must be evaluated. We developed the Esmarch closure--a simple, rapid method for closing the abdominal wall at the end of abbreviated laparotomies.

Secure Web Messaging in a Pediatric Chronic Care Clinic: A Slow Takeoff of “Kids' Airmail”

BACKGROUND: Although e-mail may be an efficient clinician-patient communication tool, standard e-mail is not adequately secure to meet Health Insurance Portability and Accountability Act (HIPAA) guidelines. For this reason, firewall-secured electronic messaging systems have been developed for use in health care. Impact and usability of these secure systems have not been broadly assessed. OBJECTIVE: To evaluate the impact of a secure electronic messaging system implemented for a pediatric subspecialty clinic. METHODS: This study was performed in an outpatient, academic pediatric respiratory clinic in spring 2009 in New Haven, Connecticut. Patients were surveyed prior to implementation regarding internet usage. The Kryptiq messaging system was implemented and messages were monitored continuously and tracked. Open-ended qualitative interviews with 28 users and nonusers were conducted, and we described the process of implementation. RESULTS: All of the 127 patients/families surveyed expressed interest in using the Internet to contact their clinic providers, and they all reported having the ability to access the Internet. In the 8 months after implementation, only 5 messages were initiated by patients in contrast to 2363 phone calls. Themes emerged from the open-ended interviews that indicated promoters, barriers, and potential uses. Prominent barriers included the lack of convenience and personal touch and being technically difficult to use. CONCLUSIONS: Although these patients/families expressed strong interest in e-mailing, secure Web messaging was less convenient than using the phone, too technically cumbersome, lacked a personal touch, and was used only by a handful of patients.

Group Asthma Education in a Pediatric Inpatient Setting

Asthma education is an important component of asthma care and management. Children and parents often do not receive asthma education, and frequently, education programs are time consuming. The purpose of this medical record review was to retrospectively determine the impact of a short, group-based, inpatient asthma self-management program on the number of children/parents who received complete asthma education before discharge. The self-management program was instituted in 2006. Participants consisted of all children admitted to a New England childrens hospital from January 1, 2005, through December 31, 2006, with a primary diagnosis of asthma. Findings revealed that significantly more (p < .001) children/parents received complete asthma education before discharge in 2006 versus 2005.

Electronic Medical Records in a Sub-Specialty Practice: One Asthma Center's Experience

There are numerous known benefits associated with the use of an electronic medical record (EMR). In October of 2004, a pediatric respiratory medicine practice at a major academic institution began the process of implementing an EMR system. Through this process, another benefit was realized, improved coordination between out-patient and in-patient care in relation to asthma education. The process began with the formation of an implementation team. The team consisted of technical as well as clinical experts from various disciplines. Together the team developed templates, decision support tools and standardized patient care letters. The team also determined workflow and provided training on the EMR system. A major benefit associated with EMR implementation was the increase in the number of children who were hospitalized with an asthma exacerbation and received an asthma action plan upon discharge. Prior to the EMR system, 4% received an asthma action plan upon discharge. After implementation of the EMR system, 58% received an asthma action plan upon discharge.

Utilization of a Second Caregiver in the Care of a Child With a Tracheostomy in the Homecare Setting

To safely discharge a child with a tracheostomy tube to home, we require two legal guardians/parents to complete a special training program. However, there are times when two parents/guardians are unavailable or unwilling to be trained. Therefore, the purpose of this study was to evaluate the role of the second caregiver of a child with a tracheostomy tube in the home setting.

Standardizing Care and Parental Training to Improve Training Duration, Referral Frequency, and Length of Stay: Our Quality Improvement Project Experience

Objectives: At our institution, there is a six bed Pediatric Respiratory Care Unit for technology dependent infants and children with a tracheostomy tube. A lack of consistency in patient care and parent/guardian education prompted our group to critically evaluate the services we provided by revisiting our teaching protocol and instituting a new model of care in the Unit. The aims of this quality improvement (QI) project were to standardize care and skills proficiency training to parents of infants with a tracheostomy tube in preparation for discharge to home. Methods: After conducting a current state survey of key unit stakeholders, we initiated a multidisciplinary, QI project to answer the question: ‘could a standardized approach to care and training lead to a decrease in parental/guardian training time, a decrease in length of stay, and/or an increase in developmental interventions for infants with tracheostomy tubes’? A convenience sample of infants with a tracheostomy tube admitted to the Pediatric Respiratory Care Unit were included in the study. Descriptive statistics were used to analyze the results. Results: Through this QI approach, we were able to decrease the time required by parents to achieve proficiency in the care of a technology dependent infant, the length of stay for these infants, and increase referral of the infants for developmental assessment. Conclusions: These outcomes have implications for how to approach deficiencies in patient care and make changes that lead to sustained improvements. HighlightsA standardized approach to parental tracheostomy training decreased duration of parental training and hospital length of stay.Institution of unit specific protocols for infants with tracheostomy tubes increased referrals to Developmental and Behavioral Pediatricians for developmental evaluations.Implementation of a structured parental tracheostomy training program resulted in positive survey comment from parents, staff, and physicians.

Lack of Identification of Asthmatic Players in a Youth Soccer League

Exercise-induced bronchoconstriction occurs in 10% to 15% of the general population and in up to 40% of youth soccer players. Sports-induced asthma exacerbations are a well-recognized cause of death in children. The aim of this descriptive study was to determine whether coaches and managers of a youth soccer league were aware of which players on their team carried the diagnosis of asthma or used bronchodilators and whether they had an emergency asthma action plan for these players. Secondary outcomes were the coaches’ and managers’ knowledge of asthma. Data collection consisted of a multiple-choice survey that was sent to 58 volunteer parent coaches and managers of a Connecticut town soccer organization. Twenty-nine (50%) coaches and managers responded to the survey; they supervised a total of 376 children. Most coaches and managers were not sure which players on their team had asthma (16, 55%) or used inhalers (17, 59%). Five (17%) coaches and managers identified 6 children who used an inhaler; 5 of the ...

Impact of Asthma Self-management on Pediatric Emergency Department Visits and Hospitalizations

Asthma education is an essential component of asthma management. Studies indicate a decrease in emergency department visits and hospitalizations when patients or parents participate in asthma self-management education programs. Because of time constraints, programs are often not offered or attended. Furthermore, variation among programs makes it difficult to generalize findings from one program to another. The purpose of this study was to compare the number of children who experienced an asthma-related emergency department visit and/or hospitalization between those whose parents attended a short, group-based, inpatient asthma self-management education program and those whose parents did not attend. A retrospective, comparative, descriptive study was conducted. Subjects consisted of a convenience sample of 298 children (attended, n = 126; did not attend, n = 172) admitted to a New England children’s hospital in 2006 with a primary diagnosis of asthma. Data from 2 hospital databases were collected for 12 mo...