Differences in testing for drugs of abuse amongst racial and ethnic groups at children's hospitals.

OBJECTIVES: Racial and ethnic differences in drug testing have been described among adults and newborns. Less is known regarding testing patterns among children and adolescents. We sought to describe the association between race and ethnicity and drug testing at US children's hospitals. We hypothesized that non-Hispanic White children undergo drug testing less often than children from other groups. METHODS: We conducted a retrospective cohort study of emergency department (ED)-only encounters and hospitalizations for children diagnosed with a condition for which drug testing may be indicated (abuse or neglect, burns, malnutrition, head injury, vomiting, altered mental status or syncope, psychiatric, self-harm, and seizure) at 41 children's hospitals participating in the Pediatric Health Information System during 2018 and 2021. We compared drug testing rates among (non-Hispanic) Asian, (non-Hispanic) Black, Hispanic, and (non-Hispanic) White children overall, by condition and patient cohort (ED-only vs. hospitalized) and across hospitals. RESULTS: Among 920,755 encounters, 13.6% underwent drug testing. Black children were tested at significantly higher rates overall (adjusted odds ratio [aOR]: 1.18; 1.05-1.33) than White children. Black-White testing differences were observed in the hospitalized cohort (aOR: 1.42; 1.18-1.69) but not among ED-only encounters (aOR: 1.07; 0.92-1.26). Asian, Hispanic, and White children underwent testing at similar rates. Testing varied by diagnosis and across hospitals. CONCLUSIONS: Hospitalized Black children were more likely than White children to undergo drug testing at US children's hospitals, though this varied by diagnosis and hospital. Our results support efforts to better understand and address healthcare disparities, including the contributions of implicit bias and structural racism.

National Imaging Trends in Pediatric Traumatic Brain Injury and Hydrocephalus.

OBJECTIVE: Reduction in use of computed tomography (CT) in favor of rapid-sequence magnetic resonance imaging (MRI) to decrease pediatric radiation exposure has varied across institutions in the United States. The aims of this study were to understand national trends in CT and rapid-sequence MRI usage and identify variables affecting imaging practices and obstacles to CT reduction. METHODS: This was a retrospective review of deidentified discharge data for children with hydrocephalus and traumatic brain injury (TBI) in the Healthcare Cost and Utilization Project Kids' Inpatient Database in 2000, 2003, 2006, 2009, 2012, and 2016. Utilization of MRI without contrast and CT was extracted using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision, codes. Hospital region and age cohorts were extracted and used to categorize data. χ2 tests and logistic regression were used for analysis. RESULTS: Hospitalizations utilizing CT decreased (P < 0.05) and hospitalizations utilizing MRI increased (P < 0.05) overall in both diagnosis groups throughout the years analyzed. However, there was significant regional variation in imaging. The Northeast had higher CT rates (P < 0.05) and the South had lower CT rates in patients with hydrocephalus and TBI (P < 0.05). No regional variation was found for rates of MRI use in patients with TBI. CONCLUSIONS: Nationwide, the average number of discharges after hospitalizations utilizing CT in patients with hydrocephalus and TBI has decreased, while discharges after hospitalizations utilizing MRI as an alternative imaging modality have increased. Despite successful overall CT reduction, significant regional variation exists within this trend showing inconsistent reduction of CT use.

Impact of a Quality Improvement Initiative to Optimize the Discharge Process of Pediatric Gastroenterology Patients at an Academic Children's Hospital.

Discharge is an important and complex process that can be optimized to reduce inpatient healthcare inefficiency and waste. This study aimed to increase the percentage of patients discharged before 1 pm by 20% from an academic inpatient pediatric gastroenterology service (IPGS), over 6 months. METHODS: We conducted a preintervention and postintervention study of patients discharged from IPGS. Patients discharged from January to June 2016, and those following our intervention from June to December 2016, were studied. Interventions included (1) implementation of the electronic medical record medical and logistical discharge criteria checklists for the 4 most common IPGS discharge diagnoses, (2) standardization of the rounds process to prioritize discharge, (3) education of nursing staff and families about the role they played in discharge. Process, outcome, and balancing measures were analyzed. RESULTS: Three hundred fifty-five total discharges were studied. Between the preintervention and postintervention groups, there were no significant improvements in discharge order time, physical discharge time, discharge response time, or discharges before 1 pm. The balancing measure of 30-day readmission was unaffected. However, length of stay (LOS) index, calculated as the ratio of actual to expected LOS, improved; when translated into days, LOS declined by 1 day, with potential associated savings of $373,000. CONCLUSIONS: Interventions to improve discharge timeliness on IPGS service demonstrated mixed effectiveness. Only LOS index improved. Further iterative quality improvement interventions are needed to continue optimizing discharge timeliness and change the culture of pediatric discharge on inpatient subspecialty services in academic children's hospitals.

Prospective Assessment of Pill-Swallowing Ability in Pediatric Patients.

Difficulty with pill-swallowing ability (PSA) is common in children, yet formal evaluation is rare. The objective of this study was to prospectively evaluate and compare PSA of inpatient and outpatient children using the Pediatric Oral Medications Screener. We identified children aged 3 to 17 years admitted to a general or subspecialty pediatric service at a university hospital or outpatient clinic. Using the Pediatric Oral Medications Screener, patients were observed swallowing 3 different-sized placebo pills (5 mm tablet, 10 mm tablet, and 22 mm capsule), and subjective measures were assessed from parents and children. We analyzed 47 inpatients and 62 outpatients. Sixteen percent of patients could not swallow any pill, 11% only swallowed the small pill, 14% swallowed up to the medium pill, and 60% swallowed all formulations. After controlling for multiple factors, inpatients had superior PSA compared with outpatients ( P = .004). These results suggest targeted inpatient screening and widespread outpatient screening would likely identify children with reduced PSA.

Review of Pediatric Osteoarticular Infections.

BACKGROUND: Pediatric osteoarticular infections are relatively rare but important diseases to identify early and treat appropriately in order to avoid associated acute complications or long-term morbidity. OBJECTIVE: To review the current epidemiology and etiology of pediatric osteoarticular infections as well as recent advances in the diagnosis and treatment of these infections. METHODS: We searched PubMed (MEDLINE) and Scopus databases for potentially relevant publications in the past 5 years. RESULTS: Bacterial epidemiology and antimicrobial resistance profiles vary greatly worldwide, although Staphylococcus aureus, streptococci and Kingella kingae are the predominant pathogens. There is emerging evidence supporting the role of PCR assays for pathogen detection. CONCLUSION: Current data suggest that most children with osteoarticular infections can be successfully transitioned to oral antibiotics after having received at least several days of intravenous therapy, undergone removal of significant infectious foci and having demonstrated clinical improvement with down trending inflammatory markers. The optimal length and route of antimicrobial therapy have not been fully elucidated and should depend on individual patient factors, the virulence of the pathogen and the monitored clinical and laboratory response to therapy.

Clindamycin Pharmacokinetics and Safety in Preterm and Term Infants.

Clindamycin may be active against methicillin-resistant Staphylococcus aureus, a common pathogen causing sepsis in infants, but optimal dosing in this population is unknown. We performed a multicenter, prospective pharmacokinetic (PK) and safety study of clindamycin in infants. We analyzed the data using a population PK analysis approach and included samples from two additional pediatric trials. Intravenous data were collected from 62 infants (135 plasma PK samples) with postnatal ages of <121 days (median [range] gestational age of 28 weeks [23 to 42] and postnatal age of 17 days [1 to 115]). In addition to body weight, postmenstrual age (PMA) and plasma protein concentrations (albumin and alpha-1 acid glycoprotein) were found to be significantly associated with clearance and volume of distribution, respectively. Clearance reached 50% of the adult value at PMA of 39.5 weeks. Simulated PMA-based intravenous dosing regimens administered every 8 h (≤32 weeks PMA, 5 mg/kg; 32 to 40 weeks PMA, 7 mg/kg; >40 to 60 weeks PMA, 9 mg/kg) resulted in an unbound, steady-state concentration at half the dosing interval greater than a MIC for S. aureus of 0.12 µg/ml in >90% of infants. There were no adverse events related to clindamycin use. (This study has been registered at ClinicalTrials.gov under registration no. NCT01728363.).

Tablet/Capsule Size Variation Among the Most Commonly Prescribed Medications for Children in the USA: Retrospective Review and Firsthand Pharmacy Audit.

INTRODUCTION: Children are frequently asked to take tablets and capsules of different sizes and shapes to manage acute and chronic medical conditions. Medication size is an important factor that contributes to compliance, yet few studies detail size variation or pediatric pharmacy inventory. OBJECTIVE: This study assesses the available sizes and size variations of common inpatient and outpatient pediatric medications and provides an inventory of the tablet and capsule sizes available in a children's inpatient hospital pharmacy. METHODS: We derived the most frequently prescribed oral medications from US national databases, including the IMS, Vector One(®): National (VONA) and Pediatric Health Information System (PHIS). We analyzed a composite list using the National Library of Medicine Pillbox website, which provides size measurements. Medications from a children's inpatient pharmacy were audited and hand measured for comparison. RESULTS: We created a list of the top 15 most prescribed inpatient and outpatient pediatric tablet/capsule medications and observed a wide variation in size: acetaminophen 500 mg ranged from 5 to 22 mm in length, median 15 mm. Common pediatric antibiotics were larger and ranged from 8 to 25 mm in length, median 17 mm. Hand-measured samples from the inpatient pharmacy were often the larger pill sizes, despite smaller alternatives being available. CONCLUSIONS: We observed a marked variation in the sizes of common pediatric tablet/capsule medications, and pharmacies that serve children may not stock the most child-friendly medications. Tablet/capsule size does not appear to be considered when decisions about tablet and capsule medication selections are made. These results should increase awareness of these sizes and affect how physicians prescribe, how pharmacies order inventory, and how insurers and pharmaceutical companies pay for and produce pediatric medications.

A Pilot Study of the Pediatric Oral Medications Screener (POMS).

OBJECTIVE: Oral medications are commonly used to treat acute and chronic conditions, but formal evaluation of a child's pill-swallowing ability rarely occurs. In this pilot study, the Pediatric Oral Medication Screener (POMS) was used to physically assess a child's pill swallowing ability and identify children who would benefit from a targeted intervention. METHODS: We identified children 3 to 17 years old admitted to a general pediatric service over a 3-month period in 2014. Patients were asked to swallow several different-sized placebo formulations. If subjects did not meet age-based goals, they were referred for pill swallowing interventions (POMS+). Follow-up parental surveys were performed for patients completing the intervention. RESULTS: The prospective pilot study recruited 34 patients. Twenty-eight patients (82%) passed the screening, and a majority of this group started or continued taking pill medications. Six did not pass the screen. Three of the 6 completed the intervention, improved their pill swallowing ability, and were taking oral pill medications at discharge. Parent prediction of pill swallowing was accurate only 56% of the time. Follow-up survey of the 3 families who completed POMS+ reported satisfaction with the program, and 2 of the patients had continued success with swallowing pills 5 months later. CONCLUSIONS: The POMS was effective at identifying children who could benefit from an intervention to improve pill-swallowing ability. Our analysis demonstrated that POMS has the potential to improve patient satisfaction and discharge planning.

Effectiveness of pediatric pill swallowing interventions: a systematic review.

BACKGROUND AND OBJECTIVE: Pediatric patients commonly have difficulty swallowing pills. Targeted interventions have shown to improve medication administration and treatment compliance. The objective was to evaluate studies performed on pill swallowing interventions in the pediatric population since 1987. METHODS: We performed a comprehensive PubMed search and a bibliography review to identify articles for our review. We selected articles published in English between December 1986 and December 2013 that included >10 participants aged 0 to 21 years with pill swallowing difficulties without a comorbid condition affecting their swallowing. Reviewers extracted the relevant information and rated the quality of each study as "poor," "fair," or "good" based on the sample size and study design. RESULTS: We identified 4 cohort studies and 1 case series that met our criteria. All 5 studies found their intervention to be successful in teaching children how to swallow pills. Interventions included behavioral therapies, flavored throat spray, verbal instructions, specialized pill cup, and head posture training. Quality ratings differed between the articles, with 3 articles rated as "fair," 1 article as "good," and 1 article as "poor." CONCLUSIONS: Pill swallowing difficulties are a barrier that can be overcome with a variety of successful interventions. Addressing this problem and researching more effective ways of implementing these interventions can help improve medication administration and compliance in the pediatric population.

Parental attitudes toward obesity and overweight screening and communication for hospitalized children.

OBJECTIVE: Many studies have evaluated BMI screening, communication, and follow-up recommendations in the outpatient setting. However, few studies have examined parental attitudes toward using the inpatient setting as a time to screen and counsel families regarding their child's BMI. We sought to study parental attitudes about overweight and obesity screening in the inpatient setting. METHODS: Parents (N= 101) of children aged 2 to 18 years admitted to a general pediatric hospital or surgical service were queried regarding their attitudes about screening and counseling for overweight and obesity. Children's age, gender, height, weight, and diagnosis codes were extracted from electronic medical records and billing databases. BMI was calculated, plotted, and categorized according to standard Centers for Disease Control and Prevention growth charts and expert recommendation. RESULTS: Fourteen percent of children in the study were overweight, and 17% were obese. Parents of overweight and obese children underestimated their child's weight status 68% of the time. The majority believed admitted children should always have their BMI calculated. Almost all parents (90%) indicated that their inpatient physician should inform them if their child were overweight or obese and that primary care providers should be informed of the results of BMI screening. CONCLUSIONS: Parents of children admitted to the hospital believed their children should have their BMI screened. If their child was overweight or obese, parents believed they should be informed, and counseling should be initiated. These findings support using the inpatient time to screen and communicate BMI.

Improving the quality of discharge communication with an educational intervention.

BACKGROUND: Communication between hospital providers and primary care physicians at the time of hospital discharge is necessary for optimal patient care and safety. Content of the inpatient discharge summary (DS) is not uniformly addressed by residency programs. OBJECTIVE: To improve DSs quality through a brief educational intervention. METHODS: We prospectively enrolled interns (first-year pediatric residents [PL1s]) in an educational intervention that consisted of a group session in which components of a high-quality DS were taught and a subsequent brief small-group session in which key components with distribution of a reminder card were reiterated. Six key components were identified: diagnosis; timely completion; pending laboratory work/studies; medications; length ≤3 pages; and discharge weight. DSs prepared by PL1s before and after the small-group session were objectively scored by blinded reviewers on the basis of how many DS components they contained (maximum score: 6). Scores were compared with historical controls of PL1s from the previous year. Audit scores were analyzed by using a mixed-effects linear regression model. RESULTS: Sixty-four PL1s were enrolled in the study; 477 DSs were scored. Mean score before the small-group reminder session was 3.6 in both groups. In mixed-effects models, scores in the intervention group increased by 0.56 points (P=.002) and DSs incorporating at least 5 of 6 components increased from 22% to 41% (P<.001) after the small-group session, whereas the control group's scores were unchanged. CONCLUSION: A brief, low-intensity educational intervention can improve quality of discharge communication and be incorporated into residency training. Electronic templates should incorporate prompts for key components of a DS.

Family member presence for procedures: the resident's perspective.

OBJECTIVE: To describe resident acceptance of and comfort with family member presence (FMP) during pediatric invasive procedures and resuscitation in a large, multicenter pediatric residency program. To determine if increased level of training impacts on opinion toward FMP for procedures. DESIGN AND METHODS: Seventy-six residents of postgraduate levels 1-4 were administered a survey about FMP for procedures. The survey consisted of 4 Likert-scale questions and 1 multiple-choice question of resident acceptance of and comfort with FMP during procedures and cardiopulmonary resuscitation (CPR). Statistical analysis was performed using the Mann-Whitney U test and one-way analysis of variance (ANOVA). RESULTS: Fifty-three residents (70%) responded. Residents were accepting of FMP during procedures, with a mean score of 3.9/5. However, residents were less accepting of FMP presence during CPR, with a mean score of 2.84/5. There was a trend toward increased comfort and acceptance of FMP with increased level of training; however, this was not statistically significant. In our study, nearly one half of residents (45%) reported that their major reservation toward FMP was that resident anxiety could result in procedure or resuscitation failure. CONCLUSION: The residents in our pediatric training program generally accept FMP for procedures. Residents were less accepting of FMP for CPR than for procedures. Residents most commonly oppose FMP for procedures because they believe this will make them anxious and lead to failure. This information provides insight into the implementation of FMP for procedures in a medical education setting.

A model of determining a fair market value for teaching residents: who profits?

CONTEXT: Centers for Medicare & Medicaid Services (CMS) Health Resources and Services Administration Children's Hospitals Graduate Medical Education (GME) Payment Program now supports freestanding children's teaching hospitals. OBJECTIVE: To analyze the fair market value impact of GME payment on resident teaching efforts in our pediatric intensive care unit (PICU). DESIGN: Cost-accounting model, developed from a 1-year retrospective, descriptive, single-institution, longitudinal study, applied to physician teachers, residents, and CMS. SETTING: Sixteen-bed PICU in a freestanding, university-affiliated children's teaching hospital. PARTICIPANTS: Pediatric critical care physicians, second-year residents. MAIN OUTCOME MEASURES: Cost of physician opportunity time; CMS investment return; the teaching physicians' investment return; residents' investment return; service balance between CMS and teaching service investment margins; economic balance points; fair market value. RESULTS: GME payments to our hospital increased 4.8-fold from 577 886 dollars to 2 772 606 dollars during a 1-year period. Critical care physicians' teaching opportunity cost rose from 250 097 dollars to 262 215 dollars to provide 1523 educational hours (6853 relative value units). Residents' net financial value for service provided to the PICU rose from 245 964 dollars to 317 299 dollars. There is an uneven return on investment in resident education for CMS, critical care physicians, and residents. Economic balance points are achievable for the present educational efforts of the CMS, critical care physicians, and residents if the present direct medical education payment increases from 29.38% to 36%. CONCLUSIONS: The current CMS Health Resources and Services Administration Children's Hospitals GME Payment Program produces uneven investment returns for CMS, critical care physicians, and residents. We propose a cost-accounting model, based on perceived production capability measured in relative value units and available GME funds, that would allow a clinical service to balance and obtain a fair market value for the resident education efforts of CMS, physician teachers, and residents.