Prothrombin Complex Concentrate Utilization in Children's Hospitals.

Prothrombin complex concentrates (PCCs) are used to manage bleeding in critically ill children. We performed a repeat cross-sectional study using the Pediatric Health Information System registry to describe PCC utilization in the U.S. children's hospitals over time and determine the relationship between PCC use and specific risk factors for bleeding. We included children < 18 years who received three-factor or four-factor PCC during hospital admission between January 2015 and December 2020 to describe the association between PCC therapy, anticoagulation therapies, and inherited or acquired bleeding diatheses. PCC use steadily increased over the 6-year study period (from 1.3 to 4.6 per 10,000 encounters). Patients exhibited a high degree of critical illness, with 85.0% requiring intensive care unit admission and a mortality rate of 25.8%. PCCs were used in a primarily emergent or urgent fashion (32.6 and 39.3%, respectively) and more frequently in surgical cases (79.0% surgical vs. 21.0% medical). Coding analysis suggested a low rate of chronic anticoagulant use which was supported by review of concomitant anticoagulant medications. PCC use is increasing in critically ill children and does not correlate with specific anticoagulant therapy use or other bleeding risk factors. These findings suggest PCC use is not limited to vitamin K antagonist reversal. Indications, efficacy, and safety of PCC therapy in children require further study.

The Association of the Childhood Opportunity Index on Pediatric Readmissions and Emergency Department Revisits.

OBJECTIVE: Reutilization following discharge is costly to families and the health care system. Singular measures of the social determinants of health (SDOH) have been shown to impact utilization; however, the SDOH are multifactorial. The Childhood Opportunity Index (COI) is a validated approach for comprehensive estimation of the SDOH. Using the COI, we aimed to describe the association between SDOH and 30-day revisit rates. METHODS: This retrospective study included children 0 to 17 years within 48 children's hospitals using the Pediatric Health Information System from 1/1/2019 to 12/31/2019. The main exposure was a child's ZIP code level COI. The primary outcome was unplanned readmissions and emergency department (ED) revisits within 30 days of discharge. Primary outcomes were summarized by COI category and compared using chi-square or Kruskal-Wallis tests. Adjusted analysis used generalized linear mixed effects models with adjustments for demographics, clinical characteristics, and hospital clustering. RESULTS: Of 728,997 hospitalizations meeting inclusion criteria, 30-day unplanned returns occurred for 96,007 children (13.2%). After adjustment, the patterns of returns were significantly associated with COI. For example, 30-day returns occurred for 19.1% (95% confidence interval [CI]: 18.2, 20.0) of children living within very low opportunity areas, with a gradient-like decrease as opportunity increased (15.5%, 95% CI: 14.5, 16.5 for very high). The relative decrease in utilization as COI increased was more pronounced for ED revisits. CONCLUSIONS: Children living in low opportunity areas had greater 30-day readmissions and ED revisits. Our results suggest that a broader approach, including policy and system-level change, is needed to effectively reduce readmissions and ED revisits.

Assessing Competence With a Task Trainer: Validity Evidence for Novel Tracheostomy Care Skills Assessment Tool.

INTRODUCTION: The purpose of this study was to develop a caregiver and healthcare provider assessment tool to evaluate essential tracheostomy skills using a simulated task trainer. METHODS: Three tracheostomy skill checklists were developed: closed suctioning, open suctioning, and tracheostomy change. Checklist items were developed based on institutional guidelines and a literature review. Items were revised based on iterative expert review and pilot testing. A total of 64 intensive care staff and 24 caregivers were evaluated using the checklists, of which 29 staff members and 4 caregivers were rated simultaneously by 2 raters to estimate interrater reliability. The relationships between checklist performance and staff demographics (experience and discipline) were calculated. A survey examining the selection of automatic fail items and minimum passing score was sent to 660 multidisciplinary staff members. RESULTS: Intraclass correlations were 0.93 for closed suctioning, 0.93 for open suctioning, and 0.76 for tracheostomy change. Staff performance only correlated with experience for the tracheostomy change checklist and was inconsistently associated with discipline (respiratory therapy vs nursing). A large, multidisciplinary survey with 132 of 660 respondents confirmed the selection of automatic fail items and minimum passing score. A total of 92.9% of the survey respondents agreed with a minimum passing score of 80%. CONCLUSIONS: We developed 3 essential tracheostomy skill checklists with multiple sources of validity evidence to support their use in a simulation-based assessment of tracheostomy skills.

A Quality Improvement Approach to Influence Value-based Mucolytic Use in the PICU.

INTRODUCTION: High-cost medication administration, despite lacking evidence for use, results in poor healthcare value. This work aimed to reduce dornase-alfa utilization in critically ill mechanically ventilated children. METHODS: The project employed an observational pre-post design to develop a value-based clinical pathway to guide provider choice in mucolytic utilization in a quaternary pediatric intensive care unit. This pathway was designed to continue using low-cost mucolytic aerosols (hypertonic saline, N-acetylcysteine) but decrease new starts and total doses per 100 patient days (P100PD) dornase-alfa among patients for whom there is little to no supporting evidence. Interventions included a departmental journal club for fellow and attending physicians and a rolling introduction of the pathway to residents and respiratory therapists. Control charts serially tracked ordering changes and location-specific dornase alfa orders. RESULTS: New dornase-alfa starts P100PD decreased by 53% (1.17-0.55), and total doses P100PD decreased by 75% (16-4). N-acetylcysteine ordering more than doubled; however, total doses of P100PD remained unchanged after the intervention. The use of 3% sodium chloride increased significantly from 0.28 to 4.15 new starts and 4.37 to 38.84 total doses P100PD. Mechanical ventilation days P100PD decreased, suggesting there were no measured adverse effects of pathway implementation. The reduction in dornase-alfa utilization resulted in a cumulative and sustained 59% mucolytic cost reduction ($2183.08-$885.77 P100PD). CONCLUSION: A clinical pathway prioritizing pharmacoeconomics when evidence for use is lacking can improve health care value without adversely affecting patient outcomes.

Screening Criteria Improve Access to Palliative Care in the PICU.

OBJECTIVES: To test the ability of palliative care screening criteria to improve access to palliative care services in the PICU and examine the association between palliative care team involvement and ICU and hospital length of stay. DESIGN: Prospective interventional quality improvement study. SETTING: PICU at a quaternary academic medical center. PATIENTS: All patients admitted to the PICU who met criteria for palliative care referral over a 9-month period. INTERVENTION: Consensus palliative care consultation criteria were created by pediatric critical care medicine and palliative care providers, and palliative care referral was encouraged for all PICU patients meeting criteria. MEASUREMENTS AND MAIN RESULTS: Palliative care referral rates increased significantly after screening criteria implementation. We identified 100 patients who were eligible for palliative care services, and referrals were made for 70 patients (70%). Patients were divided into three groups based on palliative care status: patients new to the palliative care team, patients with an existing palliative care relationship, and patients who did not have a palliative care referral. By the end of study, patients who had an existing relationship with the palliative care team were more likely to still be alive and to have limitations of medical interventions in place, whereas patients who did not have a palliative care referral were more likely to be deceased and to have died in the PICU. After correcting for other factors, including severity of illness, patients who were new to the palliative care team experienced greater delay in palliative care referral and had significantly longer PICU and hospital length of stay than those who were already known to the palliative care team. CONCLUSIONS: Palliative care screening criteria are effective tools for improving access to palliative care services in the PICU; however, widespread adoption may produce a significant increase in palliative care demand. The association between an existing palliative care relationship and reduction in resource utilization deserves further investigation as does the perceived benefit of palliative care involvement in the patient, family, and staff experience.

Outcomes following neuromuscular blockade in patients receiving tracheostomies.

OBJECTIVE: The purpose of this study is to determine whether the use of neuromuscular blockade agents (NMBAs) in pediatric patients following tracheostomy is associated with increased rates of complications or a prolonged length of stay. METHODS: This was a single-center retrospective chart review of pediatric patients undergoing tracheostomy placement between 2010 and 2013 who were admitted to the pediatric or neonatal intensive care units and did or did not receive NMBA within 7 days post-procedure. RESULTS: Out of 114 included patients, 26 (23%) received NMBAs during the postoperative period. Patients receiving NMBAs were more likely to have cardiac disease and preoperative respiratory failure but less likely to have neurologic disease. Patients receiving NMBAs had a longer median postoperative length of stay (33 vs. 23 days, p=0.043) and were more likely to have postoperative ileus (12% vs. 3%, p=0.037). CONCLUSION: In patients undergoing tracheostomy placement, use of NMBAs is associated with prolonged postoperative hospital courses. NMBAs are not associated with a higher likelihood of postoperative complications.

Purulent pericarditis secondary to community-acquired, methicillin-resistant Staphylococcus aureus in previously healthy children. A sign of the times?

RATIONALE: Purulent pericarditis secondary to community-acquired, methicillin-resistant Staphylococcus aureus (CA-MRSA) is a potentially lethal infection that has yet to be described in the pediatric population. Only four cases of purulent pericarditis secondary to CA-MRSA have been described in the English literature, all of whom were adults. OBJECTIVES: We report on the first two pediatric cases of purulent pericarditis secondary to CA-MRSA to increase awareness of this potentially fatal condition. METHODS: Clinical data were obtained from an 8-year-old male patient and a 7-month-old female patient, both previously healthy, who presented to our hospital for treatment of severe shock and multiorgan failure. Literature review was performed using MEDLINE and Cochrane databases. Pulsed-field gel electrophoresis was performed to confirm the organism type. MEASUREMENTS AND MAIN RESULTS: Our previously healthy patients presented with refractory shock and were found to have purulent pericarditis with tamponade secondary to CA-MRSA. Both patients required emergent pericardiocentesis and surgical pericardial debridement. Isolates from both patients were found to be MRSA USA type 300, a common type of CA-MRSA that has become the most frequent cause of skin and soft tissue infections in the United States. CONCLUSIONS: Purulent pericarditis survival hinges upon early empiric antibiotic therapy targeting resistant Staphylococcus, rapid diagnostic efforts, and expeditious pericardial drainage when diagnosed. An aggressive multidisciplinary approach provided for complete recovery in both cases, and both children were discharged with normal cardiac function. These two cases emphasize the need for consideration of CA-MRSA presenting with purulent pericarditis as an etiology for refractory shock.