Robert J. Vinci

Effects of maternal marijuana and cocaine use on fetal growth

To investigate the effects on infants of the use of marijuana and cocaine during pregnancy and to compare the importance of urine assays with that of interviews in ascertaining drug use, we prospectively studied 1226 mothers, recruited from a general prenatal clinic, and their infants. On the basis of either interviews or urine assays conducted prenatally or post partum, 27 percent of the subjects had used marijuana during pregnancy and 18 percent had used cocaine. When only positive urine assays were considered, the corresponding values were 16 percent and 9 percent, respectively. When potentially confounding variables were controlled for in the analysis, the infants whose mothers had positive urine assays for marijuana, as compared with the infants whose mothers were negative according to both interviews and urine assays, had a 79-g decrease in birth weight (P = 0.04) and a 0.5-cm decrement in length (P = 0.02). Women who had positive assays for cocaine, as compared with nonusers, had infants with a 93-g decrease in birth weight (P = 0.07), a 0.7-cm decrement in length (P = 0.01), and a 0.43-cm-smaller head circumference (P = 0.01). To compare our findings with those of other investigators who did not use urine assays, we repeated the analyses, considering only self-reported use of marijuana (23 percent) and cocaine (13 percent). There were no significant associations between such use as determined by interviews alone and any of the measures of outcome. We conclude that the use of marijuana or cocaine during pregnancy is associated with impaired fetal growth and that measuring a biologic marker of such use is important to demonstrate the association.

Effect of Computer Order Entry on Prevention of Serious Medication Errors in Hospitalized Children

OBJECTIVE. Although initial research suggests that computerized physician order entry reduces pediatric medication errors, no comprehensive error surveillance studies have evaluated the effect of computerized physician order entry on children. Our objective was to evaluate comprehensively the effect of computerized physician order entry on the rate of inpatient pediatric medication errors. METHODS. Using interrupted time-series regression analysis, we reviewed all charts, orders, and incident reports for 40 admissions per month to the NICU, PICU, and inpatient pediatric wards for 7 months before and 9 months after implementation of commercial computerized physician order entry in a general hospital. Nurse data extractors, who were unaware of study objectives, used an established error surveillance method to detect possible errors. Two physicians who were unaware of when the possible error occurred rated each possible error. RESULTS. In 627 pediatric admissions, with 12 672 medication orders written over 3234 patient-days, 156 medication errors were detected, including 70 nonintercepted serious medication errors (22/1000 patient-days). Twenty-three errors resulted in patient injury (7/1000 patient-days). In time-series analysis, there was a 7% decrease in level of the rates of nonintercepted serious medication errors. There was no change in the rate of injuries as a result of error after computerized physician order entry implementation. CONCLUSIONS. The rate of nonintercepted serious medication errors in this pediatric population was reduced by 7% after the introduction of a commercial computerized physician order entry system, much less than previously reported for adults, and there was no change in the rate of injuries as a result of error. Several human-machine interface problems, particularly surrounding selection and dosing of pediatric medications, were identified. Additional refinements could lead to greater effects on error rates.

Intramuscular versus oral antibiotic therapy for the prevention of meningitis and other bacterial sequelae in young, febrile children at risk for occult bacteremia

Because studies of the treatment of children with occult bacteremia have yielded conflicting results, we compared ceftriaxone with amoxicillin for therapy. Inclusion criteria were age 3 to 36 months, temperature > or = 39 degrees C, an acute febrile illness with no focal findings or with otitis media (6/10 centers), and culture of blood. Subjects were randomly assigned to receive either ceftriaxone, 50 mg/kg intramuscularly, or amoxicillin, 20 mg/kg/dose orally for six doses. Of 6733 patients enrolled, 195 had bacteremia and 192 were evaluable: 164 Streptococcus pneumoniae, 9 Haemophilus influenzae type b, 7 Salmonella, 2 Neisseria meningitidis, and 10 other. After treatment, three patients receiving amoxicillin had the same organism isolated from their blood (two H. influenzae type b, one Salmonella) and two from the spinal fluid (two H. influenzae type b), compared with none given ceftriaxone. Probable or definite infections occurred in three children treated with ceftriaxone and six given amoxicillin (adjusted odds ratio 0.43, 95% confidence interval 0.08 to 1.82, p = 0.31). The five children with definite bacterial infections (three meningitis, one pneumonia, one sepsis) received amoxicillin (adjusted odds ratio 0.00, 95% confidence interval 0.00 to 0.52, p = 0.02). Fever persisted less often with ceftriaxone (adjusted odds ratio 0.52, 95% confidence interval 0.28 to 0.94, p = 0.04). Although the difference in total infections was not significant, ceftriaxone eradicated bacteremia, prevented significantly more definite focal bacterial complications, and was associated with less persistent fever.

Medication errors related to computerized order entry for children

OBJECTIVE. The objective of this study was to determine the frequency and types of pediatric medication errors attributable to design features of a computerized order entry system. METHODS. A total of 352 randomly selected, inpatient, pediatric admissions were reviewed retrospectively for identification of medication errors, 3 to 12 months after implementation of computerized order entry. Errors were identified and classified by using an established, comprehensive, active surveillance method. Errors attributable to the computer system were classified according to type. RESULTS. Among 6916 medication orders in 1930 patient-days, there were 104 pediatric medication errors, of which 71 were serious (37 serious medication errors per 1000 patient-days). Of all pediatric medication errors detected, 19% (7 serious and 13 with little potential for harm) were computer related. The rate of computer-related pediatric errors was 10 errors per 1000 patient-days, and the rate of serious computer-related pediatric errors was 3.6 errors per 1000 patient-days. The following 4 types of computer-related errors were identified: duplicate medication orders (same medication ordered twice in different concentrations of syrup, to work around computer constraints; 2 errors), drop-down menu selection errors (wrong selection from a drop-down box; 9 errors), keypad entry error (5 typed instead of 50; 1 error), and order set errors (orders selected from a pediatric order set that were not appropriate for the patient; 8 errors). In addition, 4 preventable adverse drug events in drug ordering occurred that were not considered computer-related but were not prevented by the computerized physician order entry system. CONCLUSIONS. Serious pediatric computer-related errors are uncommon (3.6 errors per 1000 patient-days), but computer systems can introduce some new pediatric medication errors that are not typically seen in a paper ordering system.

Pediatric pre-hospital advanced life support care in an urban setting.

Objective To describe pediatric advanced life support (PALS) in a single urban environment and clarify educational priorities for ALS pre-hospital providers and pediatric medical control physicians. Methods Retrospective observational review of all pediatric pre-hospital PALS transport and medical control records of the two-tiered, unified, municipal emergency medical service of the City of Boston (catchment area 590,000) over a 1-year period. Results Of the 555 pediatric patients receiving ALS transport, 38% were for respiratory emergencies, 24% for nonrespiratory medical emergencies, 19% for traffic-related blunt trauma, and 10% for penetrating trauma. Two percent involved cardiac arrests. The most frequent procedures performed were intravenous (IV) cannulation (n = 184, 33%), bag-mask ventilation (n = 28, 5%) and intubation (n = 15, 3%). Intraosseous access was only performed in three patients (0.5%). Fifty ALS providers in the EMS system averaged pediatric IV cannulation 3.7 times, intubation 0.3 times, and intraosseous access 0.06 times per provider per year. On-line medical control was requested in 28% of PALS transports. The chief complaints managed by medical control closely mirrored the distribution of all ALS transports. The most frequent medication ordered by on-line medical control was additional nebulized albuterol after standing orders (off-line medical control) had been exhausted. Conclusions A limited number of chief complaints make up the majority of PALS transports. Initial and continuing education for ALS providers needs to reflect the importance of these critical entities. Education for urban pre-hospital providers should reflect that certain procedures will be only executed every few years (eg, pediatric intubation) or once in the career of an ALS pre-hospital provider (eg, intraosseous access). With a limited amount of pediatric teaching time, paramedic education will have to strike a careful balance between teaching about the chief complaints most frequently encountered and teaching rare, high-risk procedures that could provide maximal support for the uncommon critically ill child. On-line medical control physicians need to be prepared to direct and support the management by ALS pre-hospital providers for the chief complaints most frequently seen in pediatric patients.

An analysis of pediatric blood cultures in the postpneumococcal conjugate vaccine era in a community hospital emergency department.

Objective: Blood cultures are commonly included in the evaluation of febrile children younger than 3 years without focal source of infection. Clinicians treat patients with a positive blood culture before final identification of the organism. Their treatment might include reevaluation in the emergency department (ED), additional tests, parenteral antibiotics, and hospital admission even for children who ultimately have false-positive (FP) blood cultures. The advent of pneumococcal conjugate vaccine (PCV) has made occult bacteremia less common, decreasing the likelihood that a positive blood culture result before final organism identification will be a true pathogen. This study will identify the characteristics of patients with FP blood cultures in the post-PCV era. Methods: Charts were reviewed of all children ages 1 to 36 months with a temperature of at least 38.08°C who had a blood culture obtained in our community hospital ED from January 1997 to January 2005. Results: Bacteria grew in 106 (3.5%) out of 2971 blood cultures. True positives (TPs), defined as true pathogens, had a prevalence of 0.7%, representing 19.8% of positives. FPs, defined as contaminants, occurred in 2.8% of cultures, representing 80.2% of positives. Patients with FP cultures had lower mean white blood cell (WBC) counts (10.51 × 109/L vs. 16.95 × 109/L; P = 0.0001) and lower mean presenting temperatures (38.8°C vs. 39.4°C; P = 0.005). FPs had longer time to positivity (34.6 vs. 17.7 hours; P = 0.001) than TPs. A culture with a Gram stain suggestive of a contaminant, time to positivity greater than 24 hours and a WBC of less than 15 × 109/L had a PPV for an FP of 97%. When analysis was restricted to wellappearing children age 2 to 36 months with temperature of more than 39°C without focal source of infection who were discharged from the ED, these three criteria had a PPV for an FP of 100%. In these highly febrile children, the FPs had significantly lower WBCs (9.14 × 109/L vs. 22.84 × 109/L; P = 0.0001) and longer time topositivity (33.4 vs. 19.8 hours; P = 0.007) than TPs. The likelihood of obtaining FP cultures increased after the introduction of PCV from 62.5% to 87.8% odds ratio, 4.3; 95%confidence internal, 1.44-13.38). Conclusions: In the post-PCV era, the majority of blood culture results will be FPs. FP cultures are predictable in febrile children with WBC counts less than 15.00 × 109/L, time to positivity of more than 24 hours, and a Gram stain result suggestive of a contaminant. Prospective studies applying these criteria to the at-risk population for occult bacteremia are indicated.

Patient Handoffs: Pediatric Resident Experiences and Lessons Learned

Background: Within pediatrics, there is a paucity of data on pediatric resident handoff systems. Methods: Seventy-seven of 139 eligible pediatric housestaff participated in a cross-sectional survey that was distributed at an annual residency fall retreat in September 2007. Results: Seventy-three percent of the respondents noted uncertainty regarding patient care plans due to receipt of an incomplete verbal handoff. Nursing questions, phone, and page interruptions were noted barriers to giving an effective verbal sign-out. Personal fatigue was also reported to affect the accuracy of housestaff’s written sign-outs more than verbal sign-outs (43% vs 23%, P = .026). Only 19% of the residents reported that written sign-outs were reflective of current patient information and care plans. Conclusion: Written and verbal patient handoffs were perceived by pediatric housestaff to be important parts of patient care but often incomplete. New systems that provide a more protected handoff environment, reduce housestaff fatigue, and standardize the handoff procedure may be useful.

Youth Alcohol Use and Dating Abuse Victimization and Perpetration: A Test of the Relationships at the Daily Level in a Sample of Pediatric Emergency Department Patients Who Use Alcohol

Objective: This study retrospectively examined the daily-level associations between youth alcohol use and dating abuse (DA) victimization and perpetration for a 6-month period. Method: Timeline Followback (TLFB) interview data were collected from 397 urban emergency department patients, ages 17 to 21 years. Patients were eligible if they reported past month alcohol use and past year dating. Generalized estimating equation (GEE) analyses estimated the likelihood of DA on a given day as a function of alcohol use or heavy use (≥4 drinks per day for women, ≥5 drinks per day for men), as compared with nonuse. Results: Approximately 52% of men and 61% of women participants reported experiencing DA victimization ≥1 times during the past 6 months, and 45% of men and 55% of women reported perpetrating DA ≥1 times. For both men and women, DA perpetration was more likely on a drinking day as opposed to a nondrinking day (ORs = 1.70 and ORs = 1.69, respectively). DA victimization was also more likely on a drinking day as opposed to a nondrinking day for both men and women (ORs = 1.23 and ORs = 1.34, respectively). DA perpetration and DA victimization were both more likely on heavy drinking days as opposed to nondrinking days (2.04 and 2.03 for men’s and women’s perpetration, respectively, and 1.41 and 1.43 for men’s and women’s victimization, respectively). Conclusions: This study found that alcohol use was associated with increased risk for same day DA perpetration and victimization, for both male and female youth. We conclude that for youth who use alcohol, alcohol use is a potential risk factor for DA victimization and perpetration.

Bedside Ultrasound in the Diagnosis of Skull Fractures in the Pediatric Emergency Department

Bedside ultrasound has become a diagnostic tool that is commonly used in the emergency department. In trained hands, it can be used to diagnose multiple pathologies. In this case series, we describe the utility of ultrasound in diagnosing skull fractures in pediatric patients with scalp hematomas.

Putting the pediatrics milestones into practice: a consensus roadmap and resource analysis.

The Accreditation Council for Graduate Medical Education has partnered with member boards of the American Board of Medical Specialties to initiate the next steps in advancing competency-based assessment in residency programs. This initiative, known as the Milestone Project, is a paradigm shift from traditional assessment efforts and requires all pediatrics residency programs to report individual resident progression along a series of 4 to 5 developmental levels of performance, or milestones, for individual competencies every 6 months beginning in June 2014. The effort required to successfully make this shift is tremendous given the number of training programs, training institutions, and trainees. However, it holds great promise for achieving training outcomes that align with patient needs; developing a valid, reliable, and meaningful way to track residents’ development; and providing trainees with a roadmap for learning. Recognizing the resources needed to implement this new system, the authors, all residency program leaders, provide their consensus view of the components necessary for implementing and sustaining this effort, including resource estimates for completing this work. The authors have identified 4 domains: (1) Program Review and Development of Stakeholders and Participants, (2) Assessment Methods and Validation, (3) Data and Assessment System Development, and (4) Summative Assessment and Feedback. This work can serve as a starting point and framework for collaboration with program, department, and institutional leaders to identify and garner necessary resources and plan for local and national efforts that will ensure successful transition to milestones-based assessment.