Costs associated with acute kidney injury in critically Ill neonates with patent Ductus arteriosus: pediatric health information system (PHIS) analysis.

OBJECTIVE: Compare costs of hospitalization between critically-ill neonates with patent ductus arteriosus (PDA) who did and did not develop acute kidney injury (AKI). STUDY DESIGN: Using the Children's Hospital Association's Pediatric Health Information System (PHIS) database, we ascertained the marginal estimated total cost of hospitalization between those who did and did not develop AKI. RESULTS: Query of 49 PHIS centers yielded 14,217 neonates with PDA, 1697 with AKI and 12,520 without AKI. Predictors of cost included AKI, birth weight, ethnicity, race, length of stay (LOS), and Feudtner Complex Chronic Conditions Classification System. LOS was the strongest predictor (AKI: median 71 days [IQR 28-130]; No AKI: 28 days [10-76]; p < 0.01). Neonates with AKI had $48,416 greater costs (95% CI: $43,804-53,227) after adjusting for these predictors (AKI: $190,063, 95% CI $183,735-196,610; No AKI: $141,647, 95% CI $139,931-143,383 l; p < 0.01). CONCLUSION: AKI is independently associated with increased hospital costs in critically-ill neonates with PDA.

Preoperative in-hospital mortality in neonates with critical CHD.

OBJECTIVE: Data regarding preoperative mortality in neonates with critical CHD are sparse and would aid patient care and family counselling. The objective of this study was to utilise a multicentre administrative dataset to report the rate of and identify risk factors for preoperative in-hospital mortality in neonates with critical CHD across US centres. STUDY DESIGN: The Pediatric Health Information System database was utilised to search for newborns ≤30 days old, born 1 January 2009 to 30 June 2018, with an ICD-9/10 code for d-transposition of the great arteries, truncus arteriosus, interrupted aortic arch, or hypoplastic left heart syndrome. Preoperative in-hospital mortality was defined as patients who died prior to discharge without an ICD code for cardiac surgery or interventional catheterisation. RESULTS: Overall preoperative mortality rate was at least 5.4% (690/12,739) and varied across diagnoses (d-TGA 2.9%, TA 8.3%, IAA 5.5%, and HLHS 7.3%) and centres (0-20.5%). In multivariable analysis, risk factors associated with preoperative mortality included preterm delivery (<37 weeks) (OR 2.3, 95% CI: 1.8-2.9; p < 0.01), low birth weight (<2.5 kg) (OR 3.8, 95% CI: 3.0-4.7; p < 0.01), and genetic abnormality (OR 1.6, 95% CI: 1.2-2.2; p < 0.01). Centre average surgical volume was not a significant risk factor. CONCLUSION: Approximately 1 in 20 neonates with critical CHD suffered preoperative in-hospital mortality, and rates varied across diagnoses and centres. Better understanding of the factors that drive the variation (e.g. patient factors, preoperative care models, surgical timing) could help identify patient care improvement opportunities and inform conversations with families.

A Standardized Order-Set Improves Variability in Opioid Discharge Prescribing Patterns After Surgical Fixation of Pediatric Supracondylar Humerus Fractures.

OBJECTIVE: To evaluate institutional opioid prescribing patterns following percutaneous fixation of pediatric supracondylar humerus fractures before and after implementation of a standardized discharge order set. DESIGN: A retrospective review of patients who underwent closed reduction and percutaneous skeletal fixation of a Type II or III supracondylar humerus fracture in 2017 (prior to pain protocol implementation) and again in 2019 (after pain protocol implementation) SETTING: Single Tertiary Care Children's Hospital PARTICIPANTS: In total, 106 patients met inclusion criteria between years 2017 (n = 49) and 2019 (n = 57). Exclusion criteria included miscoded patients, open fractures, patients who presented with vascular injury or nerve palsy, polytrauma patients with multiple fractures in the same upper extremity, and supracondylar humerus fractures that underwent an open procedure. RESULTS: There were no significant differences between inpatient pain scores (p = 0.91) and MDE prescribed (p = 0.75) between the 2 cohorts. In 2017, large variability was noted in day supply of opioids (0-11.4 days) and MDE (0-8.45 mg/kg), with significant differences between prescribing patterns of junior and senior level residents (mean day supply of opioids (p = 0.045), mean MDE prescribed on discharge (p = 0.001)). After implementation of a standardized opioid discharge order set, there was a tenfold increase in the number of patients discharged without an opioid prescription (2017: 4%, 2019: 44%). Additionally, any discrepancies between prescribing practices of junior and senior level residents were eliminated (mean day supply of opioids (p = 0.65), mean MDE prescribed on discharge (p = 0.69)). CONCLUSIONS: The introduction of a standardized post-operative opioid discharge order set led to a 10-fold increase in the number of patients discharged without an opioid prescription. Additionally, the order set decreased the variability in the prescribing patterns of discharge opioid medications without change in pain control. The resident prescribing variability based upon level of experience resolved with the use of the order set.

Interhospital variation of inpatient versus outpatient pediatric burn treatment after emergency department evaluation.

BACKGROUND: Approaches to burn care in the pediatric population are highly variable and can be targeted as a potential measure in cost-reduction. We hypothesized that institutions vary significantly in treatment allocation of nonsevere burns to either inpatient or outpatient care. METHODS: We queried the PHIS database for fiscal year 2017 to quantify small pediatric burn admissions and Emergency Department visits (ED). The ICD-10 code T31.0 was used to identify burns involving <10% of total body surface area (TBSA). Centers were categorized by burn center status and length of stay, readmissions, and charges were compared. RESULTS: Inpatient versus outpatient management distribution was significantly different across the included pediatric children's hospitals (n = 34, p < 0.00001). When data were analyzed with respect to outpatient care, a bimodal distribution distinguished two groups: high hospital utilizers with an average of 30% outpatient burn care and low-utilizers averaging 87%. Median inpatient charge per patient was greater than 31-fold compared to ED burn management (p < 0.0001). CONCLUSIONS: Variability of inpatient versus outpatient pediatric burn management in small burns was significant. Compared to outpatient burn care, inpatient care is significantly more costly. Implementing protocols and personnel to provide adequate attention to small burns in the ED could be an important cost-saving measure. TYPE OF STUDY: Retrospective analysis. LEVEL OF EVIDENCE: Level III.

Effect of a Standardized Electronic Medical Record Order Set on Opioid Prescribing after Tonsillectomy.

OBJECTIVE: Approximately 5% of children develop new persistent opioid use after tonsillectomy. Critical review of our prescribing practices revealed inconsistent and excessive opioid prescribing after this procedure in children. We sought to improve our practice by using a standardized electronic medical record (EMR)-based order set. METHODS: Retrospective chart review of outpatient tonsillectomy performed before and after institution of an EMR intervention with comparison of opioid and nonopioid analgesic (NOA) prescription characteristics as well as outcomes including hemorrhage and readmission. RESULTS: Analysis of 276 preorder set and 128 post-order set tonsillectomies revealed a significant increase in NOA utilization following initiation of the order set and a significant reduction in doses of opioid prescribed. Due to a change to a stronger opioid in the order set, morphine dose equivalents (MDEs) prescribed were not decreased in the post-order set cohort. Variability between prescriptions and providers was significantly decreased in the post-order set group in terms of doses and MDEs, and dangerously high outlier prescriptions were eliminated. No differences in pain control, postoperative hemorrhage, presentation to the emergency department, or readmission were identified. DISCUSSION: An EMR-based intervention improved the quality and safety of posttonsillectomy opioid prescribing at our institution. Moving forward, this order set provides a platform with which to titrate opioid prescriptions and NOA to optimal pain control and safety levels. IMPLICATIONS FOR PRACTICE: A standardized EMR-based order set can improve the quality of opioid prescribing after tonsillectomy.

Specialty-specific reduction in opioid prescribing after common pediatric surgical operations.

BACKGROUND: Opioid misuse has reached epidemic proportions, and postoperative opioids have been linked to overdose, diversion, and dependency. We recently found our opioid prescribing practices following common pediatric operations to be inconsistent and excessive. In this study, we evaluate the efficacy of an educational intervention on opioid prescriptions following tonsillectomy and hernia repair. METHODS: Retrospective chart review of prescriptions following outpatient tonsillectomies and hernia repairs at a single institution before and after an educational intervention was performed. The intervention consisted of a single campus-wide grand rounds presentation detailing the surgeon's role in the opioid epidemic. RESULTS: Postoperative opioid prescriptions were significantly reduced for hernia repair following the educational intervention: 4.2 ± 2.9 vs 2.7 ± 2.6 days' supply (p = 0.004). Such a reduction was not observed for post-tonsillectomy opioid prescriptions: 6.3 ± 4.4 vs 5.4 ± 3.0 days' supply (p = 0.226). A greater decrease in interprovider variation was observed for hernia providers after the educational intervention than for tonsillectomy providers, though significant variation continued to be present for both procedures after the intervention. CONCLUSIONS: The efficacy of an educational intervention at reducing postoperative pediatric opioid prescribing may be tied to the specialty-specific role model relationship of the educator to the prescriber. TYPE OF STUDY: retrospective comparative chart review. LEVEL OF EVIDENCE: IV.

Inconsistent and excessive opioid prescribing after common pediatric surgical operations.

OBJECTIVES: Opioid misuse has reached epidemic proportions in the United States. Post-operative opioids have been linked to overdose, diversion, and dependency in adults, but comparatively less is known in children. We evaluated opioid prescriptions following tonsillectomy and hernia repair at our institution. METHODS: Retrospective chart review of all outpatient tonsillectomies and inguinal/umbilical hernia repairs at a single institution. Data on opioid and non-opioid analgesic prescription characteristics and post-operative pain control were reviewed. RESULTS: 470 procedures were reviewed (276 tonsillectomy, 194 hernia repair). In patients with an indication (> 5 years-old in tonsillectomy, > 1 year-old in hernia repair), 85.0% and 85.6% received a post-op opioid prescription, respectively. Mean days' opioid supplied was 6.19 +/- 4.39 days in tonsillectomy and 4.30 +/- 2.94 days for hernia repair. There was significant inter- and intra-provider variation in the days' supplied of post-operative opioid. 90-100% of patients reported adequate pain control at discharge callback regardless of pain control regimen (opioid alone, opioid + non-opioid analgesic, non-opioid analgesic alone). CONCLUSIONS: Significant variation in post-operative prescribing practices was identified as well as overall over-prescription, which will serve as a starting point to institute evidence-based intervention to reduce post-operative opioid misuse after these common pediatric surgical procedures. LEVEL OF EVIDENCE: IV.

What can we learn from first-year medical students' perceptions of pain in the primary care setting?

OBJECTIVE: Pain concerns are one of the leading causes of visits to primary care. However, practicing physicians find managing pain frustrating and complex. There is little information about how undergraduate medical students approach pain and its management. This study aimed to explore first-year medical students' perceptions of pain-related patient encounters in the primary care setting. DESIGN: Qualitative analysis was used to explore first-year students' reflective journals written during an early clinical experience in primary care. Using iterative process for text analysis, entries referencing pain-related encounters were coded by two independent researchers with 94% inter-rater reliability. Themes and categories were sought by immersion crystallization. RESULTS: Three themes emerged from the students' journals: positive, negative, and neutral perceptions of pain-related encounters. With further analysis of the journals, acute, chronic, end-of-life, iatrogenic, and emotional pain categories also emerged. Most journal entries were negative, and chronic pain generated the most negativity. CONCLUSIONS: First-year medical students identified pain as a major concern in their early clinical experience. Students' perceptions of pain-related encounters can inform curriculum design and may ultimately benefit both physicians and the patients.

The evolution of a required research program for medical students at the University of Washington School of Medicine.

The concepts and tools clinicians use to understand disease and treat patients are the direct product of basic and applied scientific inquiry. To prepare physicians to participate in this tradition of medical science, the University of Washington School of Medicine (UWSOM) created a research requirement in 1981. The objective was to provide students, during their clinical years of medical school, with first-hand experience in hypothesis-driven inquiry and an understanding of the philosophies and methods of science integral to the practice of medicine. A comprehensive curriculum review in 1998-2000 identified several limitations of this requirement. Although many students completed it successfully, others struggled to find mentors, funding, or time as coursework became more demanding. Other students found they had no interest in or aptitude for the research process itself. Accordingly, UWSOM has reaffirmed its commitment to independent inquiry but expanded the ways in which students can meet the requirement. Three research options are now available under the Independent Investigative Inquiry (III) program, generally completed the summer after students' first year of medical school. These are the hypothesis-driven inquiry, a critical review of the literature, or an experience-driven inquiry in community medicine. The goal of UWSOM is to shape new physicians who can manage rapidly changing medical science, information technology, and patient expectations in clinical practice and/or laboratories. The role of III is to teach students to develop personal methods of acquiring new knowledge and integrate it into their professional lives. Faculty support, program oversight, and funding have been increased.