A Parent Survey Assessing Association of Exposure to Gun Violence, Beliefs, and Physician Counseling.

OBJECTIVES: The study objectives are to assess associations between hospitalized children's parental exposure to gun violence (GV) and parental beliefs about guns and gun safety; secondarily, the authors aim to describe parental views on the pediatrician's role in firearm injury prevention (FIP) counseling. METHODS: Parents residing with children <20 years old hospitalized at a quaternary care hospital in a large city were eligible. Researchers administered verbal surveys between March 2017 and July 2019. We analyzed data (Wilcoxon rank-sum, χ2, or Fisher's exact tests, as appropriate) to compare the characteristics of those with exposure to GV and those without, and to assess associations of those with and without GV exposure with various beliefs. RESULTS: Enrollment included 225 parents or guardians. Although 75.5% agreed pediatricians should talk to parents about safe gun storage, 8.9% reported FIP counseling by their child's doctor. There were no substantial differences in characteristics between those with GV exposure versus those without. The study revealed that 60.0% of participants reported hearing gunshots, and 41.8% had a friend/relative who had been shot; only 29.8% reported neither. There were no differences between groups in gun-related beliefs regardless of exposure. CONCLUSIONS: In this population, there was no association between exposure to GV and gun-related beliefs. Most parents are receptive to FIP counseling, yet few have discussed FIP with their pediatrician despite high exposure to GV in this community. Nearly all parents agreed with the use of gunlocks and stricter laws for background checks. Regardless of exposure to GV, parents agreed with safe gun storage and support strengthening gun safety laws.

A Randomized Controlled Trial for Parents of Hospitalized Children: Keeping Kids Safe From Guns.

OBJECTIVES: To assess an educational intervention (BeSMART) for parents of hospitalized children on behaviors, beliefs, and knowledge about firearm safety. METHODS: A randomized controlled, 3-arm preintervention and postintervention study compared BeSMART video and handout interventions (with and without physician review) to tobacco smoke videos and handouts (control) on parental behaviors, beliefs, and knowledge. Eligibility criteria included parents and/or guardians residing with hospitalized children aged <20 years. The primary outcome was a change in parent-reported frequency of asking about guns in homes visited by their children preintervention to 1 month after intervention. Secondary outcomes were parent-reported likelihood of asking about guns in others' homes immediately postintervention and change in firearm safety beliefs and/or knowledge in the intervention versus control group, analyzed with analysis of variance. McNemar's and paired t tests compared changes within groups, and generalized estimating equations compared change between groups for the primary outcome. RESULTS: A total of 225 participants enrolled. Both intervention and control groups revealed significant increase mean in parent-reported Likert score of frequency of asking about guns within groups preintervention to 1 month after intervention (BeSMART: 1.5 to 2.3, P = .04; BeSMART + physician review: 1.4 to 1.9, P = .03; control: 1.4 to 2.3, P = .01). Change between groups was not significant (P = .81). Immediately postintervention, intervention groups reported higher likelihood of asking about guns (P < .001). Study groups revealed no significant differences in beliefs. Firearm safety knowledge increased significantly in the intervention groups. CONCLUSIONS: BeSMART firearm injury prevention intervention in a hospital setting increased parental knowledge regarding firearm safety. Immediately postintervention, BeSMART groups reported higher likelihood of asking about guns in others' homes compared with controls. At 1 month after intervention, all groups reported increased frequency asking about guns. Future investigations are needed to understand the duration of intervention impact.

Predictors of Quality Improvement in Pediatric Asthma Care.

BACKGROUND: Little is known about what hospital and emergency department (ED) factors predict performance in pediatric quality improvement efforts. OBJECTIVES: Identify site characteristics and implementation strategies associated with improvements in pediatric asthma care. METHODS: In this secondary analysis, we used data from a national quality collaborative. Data on site factors were collected via survey of implementation leaders. Data on quality measures were collected via chart review of children with a primary diagnosis of asthma. ED measures included severity assessment at triage, corticosteroid administration within 60 minutes, avoidance of chest radiographs, and discharge from the hospital. Inpatient measures included early administration of bronchodilator via metered-dose inhaler, screening for tobacco exposure, and caregiver referral to smoking cessation resources. We used multilevel regression models to determine associations between site factors and changes in mean compliance across all measures. RESULTS: Sixty-four EDs and 70 inpatient units participated. Baseline compliance was similar by site characteristics. We found significantly greater increases in compliance in EDs within nonteaching versus teaching hospitals (12% vs 5%), smaller versus larger hospitals (10% vs 4%), and rural and urban versus suburban settings (6%-7% vs 3%). In inpatient units, we also found significantly greater increases in compliance in nonteaching versus teaching hospitals (36% vs 17%) and community versus children's hospitals (23% vs 14%). Changes in compliance were not associated with organizational readiness or number of audit and feedback sessions or improvement cycles. CONCLUSIONS: Specific hospital and ED characteristics are associated with improvements in pediatric asthma care. Identifying setting-specific barriers may facilitate more targeted implementation support.

Engagement and Leadership in Firearm-Related Violence Prevention: The Role of the Pediatric Hospitalist.

Gun violence is a US public health crisis. Approximately 7000 children are hospitalized each year because of firearm-related injuries. As pediatric hospitalists, we are poised to address this crisis, whether we care directly for patients who are victims of gun violence. In this article, we aim to provide practical tools and opportunities for pediatric hospitalists to address the epidemic of gun safety and gun violence prevention, including specifics related to the inpatient setting. We provide a framework to act within 4 domains: clinical care, advocacy, education and research.

Safety of High-Flow Nasal Cannula Outside the ICU for Previously Healthy Children With Bronchiolitis.

BACKGROUND: High-flow nasal cannula (HFNC), a form of noninvasive respiratory support, is effective for the treatment of respiratory distress in ICUs. Although HFNC has been used outside of the ICU, there is little research that examines its safety in this less-monitored setting. METHODS: Children ≤ 24 months old admitted with bronchiolitis to a pediatric floor at a tertiary care center from April 1 2013, to March 31 2015, were identified by using standard diagnostic codes. Exclusion criteria were concomitant pneumonia or complex comorbidities. Demographic and clinical characteristics were abstracted. Outcomes included transfer to the ICU, higher levels of respiratory support, intubation, pneumothorax, or aspiration events. RESULTS: Eighty children admitted with bronchiolitis who were treated with HFNC while on the pediatric floor were examined. The median age was 4.6 months, 45% were girls, and the majority were either Hispanic (41%) or black (36%). Flow ranged from 3 to 10 L/min. Thirty-three subjects (41% of the sample) required subsequent transfer to the ICU. No children were intubated or developed a pneumothorax. Eighty-three percent were fed while on HFNC. No children had an aspiration event. CONCLUSIONS: HFNC may be a safe modality of respiratory support outside of the ICU for children ages ≤ 24 months with bronchiolitis and without comorbidities up to a maximum flow of 10 L/min. There were no adverse events among the subjects who were fed while on HFNC.

Clinical Factors Associated With Chest Imaging Findings in Hospitalized Infants With Bronchiolitis.

Despite recommendations against routine imaging, chest radiography (CXR) is frequently performed on infants hospitalized for bronchiolitis. We conducted a review of 811 infants hospitalized for bronchiolitis to identify clinical factors associated with imaging findings. CXR was performed on 553 (68%) infants either on presentation or during hospitalization; 466 readings (84%) were normal or consistent with viral illness. Clinical factors significantly associated with normal/viral imaging were normal temperature (odds ratio = 1.66; 95% CI = 1.03-2.67) and normal oxygen saturation (odds ratio = 1.77; 95% CI = 1.1-2.83) on presentation. Afebrile patients with normal oxygen saturations were nearly 3 times as likely to have a normal/viral CXR as patients with both fever and hypoxia. Our findings support the limited role of radiography in the evaluation of hospitalized infants with bronchiolitis, especially patients without fever or hypoxia.

Ordering Interruptions in a Tertiary Care Center: A Prospective Observational Study.

OBJECTIVES: By self-report, interruptions may contribute to up to 80% of ordering errors. A greater understanding of the frequency and context of interruptions during ordering is needed to identify targets for intervention. We sought to characterize the epidemiology of interruptions during order placement in the pediatric inpatient setting. METHODS: This prospective observational study conducted 1-hour-long structured observations on morning rounds and afternoons and evenings in the resident workroom. The primary outcome was the number of interruptions per 100 orders placed by residents and physician assistants. We assessed the role of ordering provider, number, type and urgency of interruptions and person initiating interruption. Descriptive statistics, χ2, and run charts were used. RESULTS: Sixty-nine structured observations were conducted with a total of 414 orders included. The interruption rate was 65 interruptions per 100 orders during rounds, 55 per 100 orders in the afternoons and 56 per 100 orders in the evenings. The majority of interruptions were in-person (n = 144, 61%). Interruptions from overhead announcements occurred most often in the mornings, and phone interruptions occurred most often in the evenings (P = .002). Nurses initiated interruptions most frequently. Attending physicians and fellows were more likely to interrupt during rounds, and coresidents were more likely to interrupt in the evenings (P = .002). CONCLUSIONS: Residents and physician assistants are interrupted at a rate of 57 interruptions per 100 orders placed. This may contribute to ordering errors and worsen patient safety. Efforts should be made to decrease interruptions during the ordering process and track their effects on medication errors.

3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Bronchiolitis, the most common reason for hospitalization in children younger than 1 year in the United States, has no proven therapies effective beyond supportive care. We aimed to investigate the effect of nebulized 3% hypertonic saline (HS) compared with nebulized normal saline (NS) on length of stay (LOS) in infants hospitalized with bronchiolitis. METHODS: We conducted a prospective, randomized, double-blind, controlled trial in an urban tertiary care children's hospital in 227 infants younger than 12 months old admitted with a diagnosis of bronchiolitis (190 completed the study); 113 infants were randomized to HS (93 completed the study), and 114 to NS (97 completed the study). Subjects received 4 mL nebulized 3% HS or 4 mL 0.9% NS every 4 hours from enrollment until hospital discharge. The primary outcome was median LOS. Secondary outcomes were total adverse events, subdivided as clinical worsening and readmissions. RESULTS: Patient characteristics were similar in groups. In intention-to-treat analysis, median LOS (interquartile range) of HS and NS groups was 2.1 (1.2-4.6) vs 2.1 days (1.2-3.8), respectively, P = .73. We confirmed findings with per-protocol analysis, HS and NS groups with 2.0 (1.3-3.3) and 2.0 days (1.2-3.0), respectively, P = .96. Seven-day readmission rate for HS and NS groups were 4.3% and 3.1%, respectively, P = .77. Clinical worsening events were similar between groups (9% vs 8%, P = .97). CONCLUSIONS: Among infants admitted to the hospital with bronchiolitis, treatment with nebulized 3% HS compared with NS had no difference in LOS or 7-day readmission rates.