Rebecca E. Rosenberg

Pediatric hospitalist comanagement of surgical patients: Structural, quality, and financial considerations

Comanagement of surgical patients is occurring more commonly among adult and pediatric patients. These systems of care can vary according to institution type, comanagement structure, and type of patient. Comanagement can impact quality, safety, and costs of care. We review these implications for pediatric surgical patients.

The Association between Adjuvant Pain Medication Use and Outcomes Following Pediatric Spinal Fusion.

Study Design. A comparative effectiveness database study. Objective. The aim of this study was to describe variation in use of adjuvant therapies for managing postoperative pain in in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and determine association between use of these therapies and patient outcomes. Summary of Background Data. Variation in postoperative pain management for children undergoing PSF for AIS likely impacts outcomes. Minimal evidence exists to support strategies that most effectively minimize prolonged intravenous (IV) opioids and hospitalizations. Methods. We included patients aged 10 to 18 years discharged from one of 38 freestanding childrens hospitals participating in a national database from December 1, 2012, to January 5, 2015, with ICD9 codes indicating scoliosis and PSF procedure. Use of ketorolac, gamma aminobutyric acid (GABA) analogues (GABAa), and benzodiazepines was compared across hospitals. Hierarchical logistic regression adjusting for confounders and accounting for clustering of patients within hospitals was used to estimate association between these therapies and odds of prolonged duration of IV opioids, prolonged length of stay (LOS), and early readmissions. Results. Across hospitals, use of ketorolac and GABAa was highly variable and increased over time among 7349 subjects. Use of ketorolac was independently associated with significantly lower odds of prolonged LOS [odds ratio (OR) 0.75, 95% confidence interval (95% CI) 0.64–0.89] and prolonged duration of IV opioid (OR 0.84, 95% CI 0.73–0.98). GABAa use was significantly associated with decreased odds of prolonged IV opioid use (OR 0.63, 95% CI 0.53–0.75). Readmission rate at 30 days was 1.6% and most strongly associated with prolonged LOS. Conclusion. In this national cohort of children with AIS undergoing PSF, patients who received postoperative ketorolac or GABAa were less likely to have prolonged IV opioid exposure. Given the rapid increase in use of adjuvant therapies without strong evidence, resources should be devoted to multicenter trials in order to optimize effectiveness and outcomes. Level of Evidence: 3

Implementation of an Inpatient Pediatric Sepsis Identification Pathway

BACKGROUND AND OBJECTIVE: Early identification and treatment of severe sepsis and septic shock improves outcomes. We sought to identify and evaluate children with possible sepsis on a pediatric medical/surgical unit through successful implementation of a sepsis identification pathway. METHODS: The sepsis identification pathway, a vital sign screen and subsequent physician evaluation, was implemented in October 2013. Quality improvement interventions were used to improve physician and nursing adherence with the pathway. We reviewed charts of patients with positive screens on a monthly basis to assess for nursing recognition/physician notification, physician evaluation for sepsis, and subsequent physician diagnosis of sepsis and severe sepsis/septic shock. Adherence data were analyzed on a run chart and statistical process control p-chart. RESULTS: Nursing and physician pathway adherence of >80% was achieved over a 6-month period and sustained for the following 6 months. The direction of improvements met standard criteria for special causes. Over a 1-year period, there were 963 admissions to the unit. Positive screens occurred in 161 (16.7%) of these admissions and 38 (23.5%) of these had a physician diagnosis of sepsis, severe sepsis, or septic shock. One patient with neutropenia and septic shock had a negative sepsis screen due to lack of initial fever. CONCLUSIONS: Using quality improvement methodology, we successfully implemented a sepsis identification pathway on our pediatric unit. The pathway provided a standardized process to identify and evaluate children with possible sepsis requiring timely evaluation and treatment.

Collaborations with Pediatric Hospitalists: National Surveys of Pediatric Surgeons and Orthopedic Surgeons

To understand characteristics of pediatric hospitalist (PH) involvement in the care of children admitted to surgical services and explore surgeons’ perspectives of PH effectiveness, we conducted a cross-sectional, web-based survey of pediatric surgical (PS) and pediatric orthopedic subspecialists (OS) from professional organizations. We used basic analyses to compare responses between the two surgical groups. The initial response rate was 48% (291/606) for PS and 59% (415/706) for OS. Among 185 PS and 212 OS unique programs, PH were routinely engaged (69% and 75%) in the care of surgical patients, particularly in patients with medical complexity (64% PS vs 81% OS; P = .003). PS and OS perceived positive PH impact on care coordination and comorbidity management but little on pain management or length of stay. OS were more likely than PS to view PH involvement positively (64% vs 42%; P < .001). Further research on care models, especially for children with medical complexity, is needed.

Making Comfort Count: Using Quality Improvement to Promote Pediatric Procedural Pain Management

BACKGROUND AND OBJECTIVES Pediatric procedural pain management (PPPM) is best practice but was inconsistent in our large multisite general academic medical center. We hypothesized that quality improvement (QI) methods would improve and standardize PPPM in our health system within inpatient pediatric units. We aimed to increase topical anesthetic use from 10% to 40%, improve nursing pediatric pain knowledge, and increase parent satisfaction around procedures for children admitted to a general tertiary academic medical center. METHODS We used QI methods including needs assessment, self-identified champions, small tests of change, leadership accountability, data transparency, and a train-the-peer-trainer approach to implement PPPM. We measured inpatient use of topical anesthetic (goal of 40% of admissions), nursing pain knowledge, and parent satisfaction with child comfort during procedures. We used statistical process control and basic statistics to analyze data in this interrupted time series design. RESULTS Over 18 months, use of topical lidocaine rose from 10% to 36.5% for all inpatient admissions, resulting in a centerline shift. Nursing pain knowledge scores increased 7%. Mean parent satisfaction around procedural comfort increased from 83% to 88%. CONCLUSIONS A child-focused QI initiative around PPPM can succeed in a multisite general academic medical center. Key success factors for this effort included accountability, multidisciplinary core leadership, housewide training in a novel educational evidence-based framework, and use of data and champions to promote nurse and physician engagement. Future work will focus on sustaining and monitoring change.

Provider Perspectives on Partnering With Parents of Hospitalized Children to Improve Safety

BACKGROUND AND OBJECTIVES There is increasing emphasis on the importance of patient and family engagement for improving patient safety. Our purpose in this study was to understand health care team perspectives on parent-provider safety partnerships for hospitalized US children to complement a parallel study of parent perspectives. METHODS Our research team, including a family advisor, conducted semistructured interviews and focus groups of a purposive sample of 20 inpatient pediatric providers (nurses, patient care technicians, physicians) in an acute-care pediatric unit at a US urban tertiary hospital. We used a constant comparison technique and qualitative thematic content analysis. RESULTS Themes emerged from providers on facilitators, barriers, and role negotiation and/or balancing interpersonal interactions in parent-provider safety partnership. Facilitators included the following: (1) mutual respect of roles, (2) parent advocacy and rule-following, and (3) provider quality care, empathetic adaptability, and transparent communication of expectations. Barriers included the following: (1) lack of respect, (2) differences in parent versus provider risk perception and parent lack of availability, and (3) provider medical errors and inconsistent communication, lack of engagement skills and time, and fear of overwhelming information. Providers described themes related to balancing parent advocacy with clinicians expertise, a providers personal response to challenges to the professional role, and parents balancing relationship building with escalating safety concerns. CONCLUSIONS To keep children safe in the hospital, providers balance perceived challenges to their personal and professional roles continuously in interpersonal interactions, paralleling parent concerns about role ambiguity and trust. Understanding these shared barriers to and facilitators of parent-provider safety partnerships can inform system design, parent education, and professional training.

Getting Closer to Optimizing the Prevention and Detection of VTE in Hospitalized Children

Symptomatic venous thromboembolism (VTE) in the general hospitalized pediatric population is increasing and is the second most common serious hospital-acquired condition for patients in children’s hospitals, causing significant harm and expense.1–3 Unlike other hospital-acquired conditions in children and adult VTE,4 however, there are no broadly accepted recommendations for the implementation of a standardized process of detection, prophylaxis, and treatment of VTE in hospitalized children.5 In this issue of Hospital Pediatrics , Shaughnessy and colleagues report both on variable quality-improvement (QI) success in decreasing variability in risk screening6 and in the detection of VTE events among hospitalized pediatric patients.7 We comment below first on the improvement lessons from a comparative intervention around VTE and current algorithms and then discuss the active surveillance approach for quickly identifying VTEs in hospitalized patients. Finally, we discuss how these 2 studies, taken together, can help us develop robust, population-based pediatric algorithms for preventing and addressing healthcare-acquired pediatric VTE. In their first article in this issue, Shaughnessy et al6 report on their variable success in significantly improving and sustaining the reliability of a VTE prophylaxis screening process8 to 86% and 46% in hospitalized pediatric surgery and orthopedic patients, respectively. The authors found that in addition to leadership and engagement, linking to a computerized provider order entry system postoperatively was the most impactful approach to ensuring high reliability for completing …

A New Look at Two Old Topics

#### The study In a rigorous retrospective analysis of 2090 patients admitted with acute osteomyelitis to 36 children’s hospitals from 2009 to 2012, treatment failure and adverse outcomes were compared between those receiving postdischarge peripherally inserted central catheter (PICC) versus oral antibiotic therapy. The authors used propensity scores and complex modeling to control for severity, organism, infection location, child age, and hospital, along with statistical techniques (stratified and marginal modeling) to approximate a randomized controlled trial. Cases culled from the Pediatric Health Information System database were validated with individual chart review and data enhanced. #### The key findings Treatment failure rates both across and within hospitals were similar for children with acute osteomyelitis discharged on PICC and oral antibiotics, irrespective of child age or organism. Odds of adverse outcomes, including drug reactions, emergency department visits, and complications, were significantly …

Ten-Week-Old Girl With Lethargy, Weakness, and Poor Feeding

A 10-week-old previously healthy female infant presented to a community hospital after a brief episode of choking and “turning blue” while feeding. Parents reported a 4-day history of poor feeding, weakness, weak cry, and lethargy. The baby was primarily formula fed with some breast milk and taking about 4 ounces every 4 hours, until 4 days prior to admission when, because of her poor suck, parents began spoon-feeding her 1 to 2 ounces of formula every 4 hours. Review of systems was negative for fever, cough, and diarrhea but notable for 4 days without a bowel movement. Pregnancy was uncomplicated, and prenatal labs, including group B strep, were all negative and/or within normal limits, resulting in the birth of a 3.4 kg infant at 39 weeks’ gestation. Except for a recent diagnosis of oral candidiasis, the baby had no significant past medical history, exposures, sick contacts, or travel. She was being treated with oral nystatin for the candidiasis and had received her 2-month vaccinations. Vital signs on admission were normal for age; weight was 5.2 kg. On initial neurological exam, the patient showed global hypotonia and physiological deep tendon reflexes with hoarse cry and weak suck, but no signs of respiratory distress. Complete metabolic panel and creatinine kinase were within normal limits. C-reactive protein was slightly elevated at 8.95 mg/L (normal <5 mg/L). Urinalysis was unremarkable. White blood cell count was slightly elevated at 16.2 × 10/μL with 49% neutrophils and 42% lymphocytes. No lumbar puncture was performed; head ultrasound was normal. Blood and urine cultures were negative. She was admitted for dehydration and presumed clinical sepsis, treated with 7 days of ceftriaxone and discharged home with an adaptive nipple. However, because of persistent weakness and poor feeding, the primary care pediatrician admitted the patient to a different community teaching hospital 14 days after her symptoms began. Further questioning revealed that the constipation and weakening suck were initially accompanied by general lethargy and marked head lag, which progressed to include first upperand then lower-extremity weakness. Detailed exam included the presence of normoreactive pupils, facial diplegia, diminished/absent gag, muted cry, decreased/absent deep tendon reflexes, and intact anal wink with no tongue fasciculations or ptosis. This combination of progressive peripheral descending hypotonia, facial diplegia, bulbar involvement, and decreased deep tendon reflexes strongly suggested infant botulism. After consultation with the New York City Department of Health and Mental Hygiene (NYC DOHMH), stool samples were submitted to test for botulinum toxin by mouse bioassay and for Clostridium botulinum organism by polymerase chain reaction (PCR). Serum lactate, ammonia, serum carnitine, plasma quantitative amino acids, and urine organic acids were within normal limits. Noncontrast MRI of the brain and spine were normal. The infant was then transferred to our institution for a more extensive neurological evaluation on day 16 of illness.