NEEDS AND CHALLENGES OF HOME VISITORS CONDUCTING PERINATAL DEPRESSION SCREENING.

This article describes the needs and challenges faced by home visitors, supervisors, and clients when conducting perinatal depression screening. Home visitors (n = 11), supervisors (n = 5), and clients (n = 9) representing rural and urban practice settings in Wisconsin were recruited into three separate focus groups. Themes were identified from the transcribed audio-recorded interviews using content analysis. Results indicate that a trusting relationship was leveraged to facilitate depression screening and referral. Home visitors personalized care to a client's context and to protect confidentiality. Home-visiting practice demanded flexibility and negotiation in decision-making with clients and families. Coordinating access to mental health evaluation in areas of limited access was a common challenge. Participants reported a need for further training on safety management. With adequate training and support, home visitors are well-positioned to promote access to mental health services in vulnerable families to support infant mental health.

Evaluation of quality indicators and disease damage in childhood-onset systemic lupus erythematosus patients.

The aim of this study was to describe compliance with select quality indicators and assess organ-specific dysfunction in a childhood-onset systemic lupus erythematosus population by using a validated damage index and to evaluate associations between compliance with quality indicators and disease damage. A retrospective chart review was performed on patients diagnosed with systemic lupus erythematosus prior to age 18 followed at a single center in the USA from 1999 to 2012 (n = 75). Data regarding quality indicators and outcome variables, including the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, were collected. The median disease duration was 3.8 years. The proportion of patients or patient-years in which care complied with the proposed quality measures was 94.4% for hydroxychloroquine use, 84.3% for vitamin D recommendation,75.8% for influenza vaccination (patient-years), 67.2% for meningococcal vaccination, 49.0% for ophthalmologic examination (patient-years), 31.7% for pneumococcal vaccination, and 28.6% for bone mineral density evaluation. Disease damage was present in 41.3% of patients at last follow-up, with an average damage index score of 0.81. Disease damage at last follow-up was associated with minority race/ethnicity (p = 0.008), bone mineral density evaluation (p = 0.035), and vitamin D recommendation (p = 0.018). Adherence to quality indicators in a childhood-onset systemic lupus erythematosus population is varied, and disease damage is prevalent. This study highlights the importance of quality improvement initiatives aimed at optimizing care delivery to reduce disease damage in pediatric lupus patients.

Liberation from home mechanical ventilation and decannulation in children.

BACKGROUND: The prevalence of children requiring outpatient invasive long-term mechanical ventilation is increasing. For some children, liberation from home mechanical ventilation (HMV) and decannulation is the desired outcome. This study describes our experience liberating tracheostomy and HMV (T-HMV) dependent children from respiratory technologies. METHODS: We reviewed charts of T-HMV dependent children who were cared for at our institution and decannulated between July 1999 and December 2011. Patient characteristics, diagnoses, and important steps leading to decannulation were recorded. RESULTS: Forty-six children achieved HMV independence and decannulation. The most common indications for T-HMV were lower airway and parenchymal lung disease. The median ages at tracheotomy, initiation of HMV, initiation of tracheostomy collar (TC) trials, HMV independence, and decannulation were 3.5, 6.0, 12.0, 25.5, and 40.5 months, respectively. Twenty-five children (54%) skipped either using a speaking valve, tracheostomy capping, or both without increased likelihood of recannulation. (P = 0.03). Common procedures prior to decannulation were airway surgery, bronchoscopy, and polysomnography (n = 30, 46, and 46 children, respectively). A median of 9.5 clinic visits and 5 hospitalizations occurred from initial hospital discharge to just prior to decannulation. HMV was primarily weaned as an outpatient. CONCLUSION: Liberation from respiratory technology is a complex, multi-step process that can be accomplished in medically complex children with varying underlying disease processes at relatively young ages. Five major steps (tracheotomy, initiation of HMV, initiation of TC trials, HMV independence, and decannulation) performed in conjunction with clinic visits, procedures, and home nursing support were integral in the successful decannulation process. Pediatr Pulmonol. 2016;51:838-849. © 2016 Wiley Periodicals, Inc.

Improving Pneumococcal Vaccination in Pediatric Rheumatology Patients.

BACKGROUND AND OBJECTIVE: Many pediatric rheumatology patients are at increased risk of pneumococcal disease secondary to a deficient immune system and/or immunosuppressive medications. The goal of this study was to improve pneumococcal vaccination rates in this high-risk population. METHODS: Eligible patients included children at least 2 years old and adults with systemic lupus erythematosus and/or currently on immunosuppressive medication. Interventions included a presentation to rheumatology providers,creation of immunization algorithm, previsit planning, placing reminders on clinic forms, and sending reminder e-mails to providers. Chart reviews were performed, and control charts were established to portray change in immunization rates. RESULTS: The preintervention immunization rates for 90 patient visits compared with the immunization rates for the 53-week postintervention period with 1033 patient visits and 299 separate patients were all statistically significant.The 13-valent pneumococcal conjugate vaccine rate increased from 6.7% to48.4% (x2 = 58.3, P , .001), 23-valent pneumococcal polysaccharide vaccinerate increased from 8.9% to 28.4% (x2 = 16.0, P , .001), and combined rate increased from 0% to 23.2% (x2 = 25.2, P , .001). The improvement was sustained with shifts in the data for each vaccine and combined immunizations for final average rates of 60.9% for 13-valent pneumococcal conjugate vaccine, 39.2% for 23-valent pneumococcal polysaccharide vaccine,and 33.7% for combined. CONCLUSIONS: Pneumococcal vaccination is an important part of the care for systemic lupus erythematosus patients and patients on immunosuppressive medications. Simple interventions through this quality improvement project led to a marked increase in pneumococcal vaccination rates in this vulnerable population.

Using "teach-back" to promote a safe transition from hospital to home: an evidence-based approach to improving the discharge process.

The "teach-back" process is a comprehensive, interdisciplinary, evidence-based strategy which can empower nursing staff to verify understanding, correct inaccurate information, and reinforce medication teaching and new home care skills with patients and families. The Evidence-Based Practice Fellows at Children's Hospital of Wisconsin designed and implemented an educational intervention for nurses on "teach-back" which encouraged nurses to check for patients' and caregivers' understanding of discharge instructions prior to discharge. Pre and post survey data collected from nurses specifically demonstrated the positive effect "teach-back" could have on preventing medication errors while also simultaneously identifying areas for further study.

Can utilization review criteria be used to determine appropriate pediatric patient placement for a critical care bed expansion?

The rising trend in critical care utilization has led to the expansion of critical care beds in many hospitals across the country. Traditional models of estimating bed capacity requirements use administrative data such as inpatient admissions, length of stay, and case mix index. The use of such data has been limited in quantifying the complexities of demand variables in critical care bed needs. Mathematical modeling is another method for estimating numbers of beds required. It captures the dynamic changes in the management of critically ill patients that occur when units become full. Depending on data analysis methods used, bed need underestimation or overestimation can occur. In our study, we used utilization review criteria to understand changes in level of care (LOC) during the course of patients' stays and to validate critical care bed expansion needs. Using LOC criteria, we studied the proportion of our intermediate care patients in an acute care unit that met acute, intermediate, or critical care criteria. We also evaluated whether these proportions were related to specific factors such as census ratios, staffing proportions, or severity of illness. Using LOC criteria was helpful in validating our critical care bed projection, which was previously derived from mathematical modeling. The findings also validated our assessment for additional specialty acute care beds.