A Quality Improvement Initiative to Transform Seasonal Immunization Processes Using Learning from the Coronavirus 2019 Pandemic.

Background: Surge demands for annual influenza vaccines challenge healthcare systems. Mass immunizations differ from the traditional care model. The coronavirus 2019 (COVID-19) pandemic challenged current care models with amplified demand and infection risks while challenging the organization to create new and improve existing processes. Methods: Using the Model for Improvement, the team set out to (1) safely meet a surge in vaccination demand and (2) adopt pandemic-driven innovations into routine immunization practice. Results: This free-standing pediatric system delivered 87,000 COVID-19 vaccines (~1.3% state total). It administered over 50% of COVID-19 vaccines using new mass immunization processes, including 37,000 adult vaccines before pediatric authorization. In the 2021-2022 influenza season, it used the new or improved immunization processes to deliver 22% of influenza vaccines. Conclusions: Pandemic-driven adaptation for the COVID-19 vaccine substantially increased the efficiency of influenza vaccination processes but did not result in a clear increase in influenza vaccine administration rates.

Identifying asthma-related risks during hospitalization using the child asthma risk assessment tool.

Objective: The Child Asthma Risk Assessment Tool (CARAT) identifies risk factors for asthma morbidity. We hypothesized that CARAT-identified risk factors (using a CARAT adapted for inpatient use) would be associated with future healthcare utilization and would identify areas for intervention.Methods: We reviewed CARAT data collected during pediatric asthma admissions from 2010-2015, assessing for risk factors in environmental, medical, and social domains and providing prompts for inpatient (specialist consultation or social services engagement) and post-discharge interventions (home care visit or home environmental assessment). Confirmatory factor analysis identified groups of CARAT-identified risk factors with similar effects on healthcare utilization (latent factors). Structural equation models then evaluated relationships between latent factors and future utilization.Results: There were 2731 unique patients admitted for asthma exacerbations; 1015 (37%) had complete CARAT assessments and were included in analyses. Those with incomplete CARAT assessments were more often younger and privately-insured. CARAT-identified risk factors across domains were common in children hospitalized for exacerbations. Risks in the environmental domain were most common. Inpatient asthma consults by pulmonologists or allergists and home care referrals were the most frequent interventions indicated (62%, 628/1015, and 50%, 510/1015, respectively). Two latent factors were positively associated with healthcare utilization in the year after index stay - social stressors and known/suspected allergies (both p < 0.05). Stratified analyses analyzing data just from those children with prior healthcare utilization also indicated known/suspected allergies to be positively associated with future utilization.Conclusions: Inpatient interventions to address social stressors and allergic profiles may be warranted to reduce subsequent asthma morbidity.

Abnormal Newborn Screening Follow-up for Severe Combined Immunodeficiency in an Amish Cohort with Cartilage-Hair Hypoplasia.

Cartilage-hair hypoplasia (CHH) is an autosomal recessive, short limb skeletal dysplasia with a variable immunologic phenotype. The spectrum of immune function ranges from clinically normal to severe combined immunodeficiency (SCID). Multiple studies have shown that abnormal immune parameters may not predict severe outcomes. Newborn screening (NBS) using T cell receptor excision circle (TREC) assay can now effectively identify infants with severe T cell deficiency who are at risk for SCID. NBS has allowed for cost-effective identification of patients with SCID and improved outcomes with hematopoietic stem cell transplant (HSCT). Ohio reports two abnormal TREC results: decreased and absent TREC. This study evaluated the laboratory and clinical differences in eight Amish patients with CHH with an abnormal TREC result on the NBS. There were four patients with absent TREC and four patients with decreased TREC. The absent TREC patients had lower CD3, CD4, naïve CD4, CD8 cells, and phytohemagglutinin (PHA)-induced lymphocyte proliferation. Three patients with absent TREC were diagnosed with SCID and two underwent successful HSCT. Patients with absent TREC experienced more CHH-related morbidity including anemia requiring transfusion, Hirschsprung's disease, and failure to thrive. No patients with decreased TREC required HSCT. Our study indicates that CHH patients with absent TREC tend to have more severe immunological and clinical phenotype than patients with decreased TREC. Confirmation of these trends in a larger group would guide providers and parents in a timely referral for HSCT, or cost-effective surveillance monitoring of children with a life-threatening illness.

Use of a Clinical Care Algorithm to Improve Care for Children With Hematogenous Osteomyelitis.

BACKGROUND AND OBJECTIVES: Acute hematogenous osteomyelitis (AHO) causes significant morbidity in children. Quality improvement (QI) methods have been used to successfully improve care and decrease costs through standardization for numerous conditions, including pediatric AHO. We embarked on a QI initiative to standardize our approach to the inpatient management of AHO, with a global aim of reducing inpatient costs. METHODS: We used existing literature and local consensus to develop a care algorithm for the inpatient management of AHO. We used the Model for Improvement as the framework for the project, which included process mapping, failure mode analysis, and key driver identification. We engaged with institutional providers to achieve at least 80% consensus regarding specific key drivers and tested various interventions to support uptake of the care algorithm. RESULTS: Fifty-seven patients were included. There were 31 patients in the preintervention cohort and 26 in the postintervention cohort, of whom 19 were managed per the algorithm. Mean inpatient charges decreased from $45 718 in the preintervention cohort to $32 895 in the postintervention cohort; length of stay did not change. Adherence to recommended empirical antimicrobial agents trended upward. CONCLUSIONS: A simple and low-cost QI project was used to safely decrease the cost of inpatient care for pediatric AHO at a tertiary care children's hospital. A robust local consensus process proved to be a key component in the uptake of standardization.

A comparison of the polycation receptors of Paramecium tetraurelia and Tetrahymena thermophila.

Chemorepellents are compounds that cause ciliated protozoans to reorient their swimming direction. A number of chemorepellents have been studied in the ciliated protozoans, Paramecium and Tetrahymena. Chemorepellents, such as polycations, cause the organism to exhibit "avoidance behavior," a swimming behavior characterized by jerky movements and other deviations from normal forward swimming, which result from ciliary reversal. One well-characterized chemorepellent pathway in Tetrahymena is that of the proposed polycation receptor that is activated by lysozyme and pituitary adenylate cyclase activating polypeptide (PACAP). In this study, we compare the response of Paramecium to the chemorepellents lysozyme, vasoactive intestinal peptide (VIP), and PACAP to the previously studied polycation response in Tetrahymena. Our results indicate that lysozyme, VIP, and PACAP are all chemorepellents in Paramecium, just as they are in Tetrahymena. However, the signaling pathways involved appear to be different. While previous pharmacological characterization indicates that G-proteins are involved in polycation signaling in Tetrahymena, we present evidence that similar reception in Paramecium involves activation of a tyrosine kinase pathway in order for lysozyme avoidance to occur. Polycation responses of both organisms are inhibited by neomycin sulfate. While PACAP is the most effective of the three chemorepellents in Tetrahymena, lysozyme is the most effective chemorepellent in Paramecium.