Kelly Horan

Developmental Screening: Is There Enough Time?

Objectives . The American Academy of Pediatrics recommends routine developmental screening in well-child care. Providers cite time restraints as a limitation preventing its widespread adoption. The objectives were to determine whether routine screening lengthened well-visits and was associated with changes in parent satisfaction and report of anticipatory guidance. Methods. Visits before and after implementation of routine screening were timed. Parents whose children were seen before or after screening began were contacted to query their perceptions of the visit. Results. There was no change in visit lengths after the screener was included. With screening, more parents reported their provider talked about their concerns, and that their questions were answered. There were no changes in parent satisfaction ratings or reports of anticipatory guidance discussions. Conclusions. The perceived obstacle that routine screening requires more time than pediatricians have should not prevent its adoption. Screening tools may empower some parents otherwise reluctant to raise concerns unsolicited.

Ventilator-Associated Events in Neonates and Children--A New Paradigm.

Objectives:To identify a pediatric ventilator-associated condition definition for use in neonates and children by exploring whether potential ventilator-associated condition definitions identify patients with worse outcomes. Design:Retrospective cohort study and a matched cohort analysis. Setting:Pediatric, cardiac, and neonatal ICUs in five U.S. hospitals. Patients:Children 18 years old or younger ventilated for at least 1 day. Interventions:None. Measurements and Main Results:We evaluated the evidence of worsening oxygenation via a range of thresholds for increases in daily minimum fraction of inspired oxygen (by 0.20, 0.25, and 0.30) and daily minimum mean airway pressure (by 4, 5, 6, and 7 cm H2O). We required worsening oxygenation be sustained for at least 2 days after at least 2 days of stability. We matched patients with a ventilator-associated condition to those without and used Cox proportional hazard models with frailties to examine associations with hospital mortality, hospital and ICU length of stay, and duration of ventilation. The cohort included 8,862 children with 10,209 hospitalizations and 77,751 ventilator days. For the fraction of inspired oxygen 0.25/mean airway pressure 4 definition (i.e., increase in minimum daily fraction of inspired oxygen by 0.25 or mean airway pressure by 4), rates ranged from 2.9 to 3.2 per 1,000 ventilator days depending on ICU type; the fraction of inspired oxygen 0.30/mean airway pressure 7 definition yielded ventilator-associated condition rates of 1.1–1.3 per 1,000 ventilator days. All definitions were significantly associated with greater risk of hospital death, with hazard ratios ranging from 1.6 (95% CI, 0.7–3.4) to 6.8 (2.9–16.0), depending on thresholds and ICU type. Each definition was associated with prolonged hospitalization, time in ICU, and duration of ventilation, among survivors. The advisory board of the study proposed using the fraction of inspired oxygen 0.25/mean airway pressure 4 thresholds to identify pediatric ventilator-associated conditions in ICUs. Conclusions:Pediatric patients with ventilator-associated conditions are at substantially higher risk for mortality and morbidity across ICUs, regardless of thresholds used. Next steps include identification of risk factors, etiologies, and preventative measures for pediatric ventilator-associated conditions.

Developmental Screening With Spanish-Speaking Families in a Primary Care Setting

Cultural beliefs may influence parents’ willingness to raise concerns on a developmental screener. Our study evaluated the performance of the Parents’ Evaluation of Developmental Status (PEDS) in an urban community health center where 75% of families are Spanish speaking. Our primary outcome was the presence of parent-reported concerns either in the medical record or on the PEDS before the PEDS was introduced compared with after it became routine care (post-PEDS). Covariates included family language and child age, gender, and risk status. The adjusted odds of a concern being identified was 1.5 times greater in the post-PEDS period for Developmental concerns and 2.1 times greater for Behavioral concerns. There was no association with family language indicating that the PEDS performs equally well for English- and Spanish-speaking families. The systematic inclusion of developmental screening as part of culturally competent primary care may aid in reducing current disparities in the identification of developmental concerns.

Racial disparities in family-provider interactions for pediatric asthma care

ABSTRACT Objective: Black and Latino children experience significantly worse asthma morbidity than their white peers for multifactorial reasons. This study investigated differences in family-provider interactions for pediatric asthma, based on race/ethnicity. Methods: This was a cross-sectional study of parent surveys of asthmatic children within the Population-Based Effectiveness in Asthma and Lung Diseases Network. Our study population comprised 647 parents with survey response data. Data on self-reported race/ethnicity of the child were collected from parents of the children with asthma. Outcomes studied were responses to the questions about family-provider interactions in the previous 12 months: (1) number of visits with asthma provider; (2) number of times provider reviewed asthma medications with patient/family; (3) review of a written asthma treatment plan with provider; and (4) preferences about making asthma decisions. Results: In multivariate adjusted analyses controlling for asthma control and other co-morbidities, black children had fewer visits in the previous 12 months for asthma than white children: OR 0.63 (95% CI 0.40, 0.99). Additionally, black children were less likely to have a written asthma treatment plan given/reviewed by a provider than their white peers, OR 0.44 (95% CI 0.26, 0.75). There were no significant differences by race in preferences about asthma decision-making nor in the frequency of asthma medication review. Conclusion: Black children with asthma have fewer visits with their providers and are less likely to have a written asthma treatment plan than white children. Asthma providers could focus on improving these specific family-provider interactions in minority children.

Factors Associated With Pediatric Ventilator-Associated Conditions in Six U.S. Hospitals: A Nested Case-Control Study.

Objectives: A newly proposed surveillance definition for ventilator-associated conditions among neonatal and pediatric patients has been associated with increased morbidity and mortality among ventilated patients in cardiac ICU, neonatal ICU, and PICU. This study aimed to identify potential risk factors associated with pediatric ventilator-associated conditions. Design: Retrospective cohort. Setting: Six U.S. hospitals Patients: Children less than or equal to 18 years old ventilated for greater than or equal to 1 day. Interventions: None. Measurements and Main Results: We identified children with pediatric ventilator-associated conditions and matched them to children without ventilator-associated conditions. Medical records were reviewed for comorbidities and acute care factors. We used bivariate and multivariate conditional logistic regression models to identify factors associated with ventilator-associated conditions. We studied 192 pairs of ventilator-associated conditions cases and matched controls (113 in the PICU and cardiac ICU combined; 79 in the neonatal ICU). In the PICU/cardiac ICU, potential risk factors for ventilator-associated conditions included neuromuscular blockade (odds ratio, 2.29; 95% CI, 1.08–4.87), positive fluid balance (highest quartile compared with the lowest, odds ratio, 7.76; 95% CI, 2.10–28.6), and blood product use (odds ratio, 1.52; 95% CI, 0.70–3.28). Weaning from sedation (i.e., decreasing sedation) or interruption of sedation may be protective (odds ratio, 0.44; 95% CI, 0.18–1.11). In the neonatal ICU, potential risk factors included blood product use (odds ratio, 2.99; 95% CI, 1.02–8.78), neuromuscular blockade use (odds ratio, 3.96; 95% CI, 0.93–16.9), and recent surgical procedures (odds ratio, 2.19; 95% CI, 0.77–6.28). Weaning or interrupting sedation was protective (odds ratio, 0.07; 95% CI, 0.01–0.79). Conclusions: In mechanically ventilated neonates and children, we identified several possible risk factors associated with ventilator-associated conditions. Next steps include studying propensity-matched cohorts and prospectively testing whether changes in sedation management, transfusion thresholds, and fluid management can decrease pediatric ventilator-associated conditions rates and improve patient outcomes.

Embedding Field Research on Mentored Inclusive Recreation in an Urban Population—The Evolution of Opening Doors: Project Adventure

Community-based interventions have greater relevance and a greater chance of success and sustainability when the community is collaboratively involved in the research process. Opening Doors: Project Adventure is a research project designed to evaluate the impact of community-based inclusive recreation, using supportive mentoring, on children and youth with disabilities and special health care needs (CYDS). The project has a central goal of engaging CYDS who are members of underrepresented minorities, including those who face linguistic, cultural, and/or financial barriers to participation. In this article we describe the process of working with community partners and the lessons learned in the development and implementation of Project Adventure.

Impact of the 2012 Medicaid Health Care–Acquired Conditions Policy on Catheter-Associated Urinary Tract Infection and Vascular Catheter–Associated Infection Billing Rates

Abstract In July 2012, the Centers for Medicare & Medicaid Services ceased hospital Medicaid reimbursements for certain health care–acquired conditions. Using billing data from 2008–2014, we found no impact of this policy on rates of 2 targeted conditions, vascular catheter–associated infections and catheter-associated urinary tract infections, among Medicaid or non-Medicaid patients.

The impact of the Medicaid healthcare-associated condition program on mediastinitis following coronary artery bypass graft:

OBJECTIVEIn 2012, the Centers for Medicare and Medicaid Services expanded a 2008 program that eliminated additional Medicare payment for mediastinitis following coronary artery bypass graft (CABG) to include Medicaid. We aimed to evaluate the impact of this Medicaid program on mediastinitis rates reported by the National Healthcare Safety Network (NHSN) compared with the rates of a condition not targeted by the program, deep-space surgical site infection (SSI) after knee replacement.DESIGNInterrupted time series with comparison group.METHODSWe included surveillance data from nonfederal acute-care hospitals participating in the NHSN and reporting CABG or knee replacement outcomes from January 2009 through June 2017. We examined the Medicaid programs impact on NHSN-reported infection rates, adjusting for secular trends. The data analysis used generalized estimating equations with robust sandwich variance estimators.RESULTSDuring the study period, 196 study hospitals reported 273,984 CABGs to the NHSN, resulting in 970 mediastinitis cases (0.35%), and 294 hospitals reported 555,395 knee replacements, with 1,751 resultant deep-space SSIs (0.32%). There was no significant change in incidence of either condition during the study. Mediastinitis models showed no effect of the 2012 Medicaid program on either secular trend during the postprogram versus preprogram periods (P=.70) or an immediate program effect (P=.83). Results were similar in sensitivity analyses when adjusting for hospital characteristics, restricting to hospitals with consistent NHSN reporting or incorporating a program implementation roll-in period. Knee replacement models also showed no program effect.CONCLUSIONSThe 2012 Medicaid program to eliminate additional payments for mediastinitis following CABG had no impact on reported mediastinitis rates.Infect Control Hosp Epidemiol 2018;39:694-700.