Comparison of mindfulness interventions for healthcare professionals: A mixed-methods study.

OBJECTIVES: Burnout is increasingly a concerning problem in US Healthcare systems. Although the causes of burnout are not predominantly due to individual factors, mindfulness instruction is an evidence-based approach to counteracting burnout. Our health system initiated a multi-pronged approach to mindfulness instruction for our employees and community. We aimed to assess the impact of these varied programs. METHODS: Several mindfulness courses of different lengths were employed. Validated survey instruments were administered to participants before and after the courses to assess stress, mindfulness and burnout. Pre-course and post-course results were compared for each intervention. Free-text responses were also captured and analyzed in a qualitative fashion. RESULTS: Participants in MBIs demonstrated statistically significant improvement in burnout and perceived stress on post-course survey results. Several mindfulness domains also showed statistically significant improvement (awareness, non-react and observe). There was no difference in the observed results between the mindfulness interventions. Qualitative analysis yielded three themes: seeking help, symptoms, and changes in mindfulness practice. CONCLUSIONS: MBIs designed for employees of an academic medical center were associated with positive quantitative and qualitative results. All MBI participants achieved improvement in perceived stress and mindfulness as well as reduction in burnout, regardless of course length.

Nine Seasons of a Bronchiolitis Observation Unit and Home Oxygen Therapy Protocol.

BACKGROUND: We implemented an observation unit and home oxygen therapy (OU-HOT) protocol at our children's hospital during the 2010-2011 winter season to facilitate earlier discharge of children hospitalized with bronchiolitis. An earlier study demonstrated substantial reductions in inpatient length of stay and costs in the first year after implementation. OBJECTIVE: Evaluate long-term reductions in length of stay and cost. DESIGN, SETTING, AND PARTICIPANTS: Interrupted time-series analysis, adjusting for patient demographic factors and disease severity. Participants were children aged 3 to 24 months and hospitalized with bronchiolitis from 2007 to 2019. INTERVENTION: OU-HOT protocol implementation. MAIN OUTCOME AND MEASURES: Hospital length of stay. Process measures were the percentage of patients discharged from the OU; percentage of patients discharged with HOT. Balancing measures were 7-day hospital revisit rates; annual per-population bronchiolitis admission rates. Secondary outcomes were inflation-adjusted cost per episode of care and discharges within 24 hours. RESULTS: A total of 7,116 patients met inclusion criteria. The OU-HOT protocol was associated with immediate decreases in mean length of stay (-30.6 hours; 95% CI, -37.1 to -24.2 hours) and mean cost per episode of care (-$4,181; 95% CI, -$4,829 to -$3,533). These findings were sustained for 9 years after implementation. Hospital revisit rates did not increase immediately (-1.1% immediate change; 95% CI, -1.8% to -0.4%), but a small increase in revisits was observed over time (change in slope 0.4% per season, 95% CI, 0.1%-0.8%). CONCLUSION: The OU-HOT protocol was associated with sustained reductions in length of stay and cost, representing a promising strategy to reduce the inpatient burden of bronchiolitis.

Pediatric Bacterial Tracheitis-A Variable Entity: Case Series with Literature Review.

OBJECTIVE: To review the presentation and treatment of children diagnosed with bacterial tracheitis at our institution and to review the available literature focusing on key presenting symptoms and clinical outcomes of children diagnosed with bacterial tracheitis. STUDY DESIGN: Case series with literature review. SETTING: Tertiary children's hospital and available literature. SUBJECTS AND METHODS: Case series of children with bacterial tracheitis retrospectively reviewed at a tertiary children's hospital. Those with a tracheostomy or those who developed bacterial tracheitis as a complication of prolonged intubation were excluded. RESULTS: Thirty-six children were identified (mean ± SD age, 6.7 ± 4.5 years). The most common presenting symptom was cough (85%), followed by stridor (77%) and voice changes/hoarseness (67%). A concurrent viral illness was found for 55%, and the most common bacteria cultured was methicillin-sensitive Staphylococcus aureus. Pediatric intensive care admission occurred for 69%, and 43% required intubation. No patient required tracheostomy. One patient (2.7%) died secondary to airway obstruction and subsequent respiratory arrest. Four patients had recurrence of bacterial tracheitis 4 to 12 months following their initial presentation. CONCLUSION: Bacterial tracheitis is an uncommon condition with an atypical presentation and variable clinical course but serious consequences if left unrecognized. Staphylococcus is the most common bacteria identified, and many patients will have a prodromal viral illness. Changes in patient epidemiology and presentation may have occurred over time.

Implementing a Standardized Constipation-Management Pathway to Reduce Resource Utilization.

OBJECTIVE: Constipation is commonly diagnosed in our pediatric emergency department (ED). Care has varied significantly, with a heavy reliance on abdominal radiography (AR) for the diagnosis of and inpatient management for bowel cleanout. We implemented a standardized approach to caring for patients presenting to a pediatric ED with symptoms consistent with constipation, emphasizing clinical history, physical examination, less reliance on AR, and standardized home management. METHODS: Using quality improvement (QI) methodology, a multidisciplinary group developed an ED constipation management pathway, encouraging less reliance on AR for diagnosis and promoting home management over inpatient bowel cleanout. The pathway included a home management "gift basket" containing over-the-counter medications and educational materials to promote successful bowel cleanout. Outcome measures included pathway utilization, AR rate, ED cost and length of stay, and ED admission rate for constipation. RESULTS: Within 3 months, >90% of patients discharged home with an ED disposition diagnosis of constipation left with standardized educational materials and home medications. Staff education and feedback, pathway and gift basket changes, and a higher threshold for inpatient management led to significant decreases in AR rate (73.3%-24.6%, P < .001), average per-patient cost ($637.42-$538.85), length of stay (223-196 minutes, P < .001), and ED admission rate (15.3%-5.4%, P < .001), with no concerning missed diagnoses or increases in ED revisit rate. CONCLUSIONS: An ED QI project standardizing the care of pediatric constipation was implemented successfully, leading to a sustainable decrease in resource utilization. The next phase of the project will focus on collaborating with community providers to reduce ED utilization.

Reducing hospital admissions of healthy children with functional constipation: a quality initiative.

Functional constipation (FC) is a common medical problem in children, with minimal risk of long-term complications. We determined that a large number of children were being admitted to our children's hospital for FC in which there was no neurological or anatomical cause. Our hospital experienced a patient complication in which a patient died after inpatient treatment of FC. Subsequently, we developed a standardised approach to determine when paediatric patients needed hospitalisation for FC, as well as to develop a regimented outpatient therapeutic approach for such children to prevent hospitalisation. Our quality improvement initiative resulted in a large decrease in the number of children with FC admitted into the hospital as well as a decrease in the number of children needing faecal disimpaction in the operating room. Our quality improvement process can be used to decrease hospitalisations, decrease healthcare costs and improve patient care for paediatric FC.

Outpatient management of home oxygen for bronchiolitis.

OBJECTIVE: Home O2 has been shown to reduce hospitalizations for bronchiolitis but data on outpatient management of home O2 are lacking. We aim to describe outpatient management and challenges to home O2 for bronchiolitis. METHODS: We surveyed Colorado and Utah (where home O2 use is prevalent) chapter members of the American Academy of Pediatrics regarding bronchiolitis home O2 management. RESULTS: A total of 1030 providers were surveyed. The response rate was 21% (n = 214). Ninety percent of practicing primary care providers reported experience with home O2. Of those, 46% see patients on postdischarge day 1. Most providers see patients 1 to 3 times before stopping O2. Eighty percent continue O2 for 3 to 7 days. Weaning procedures vary and 56% practice more than 1 method. Most (41%) do not use continuous pulse oximetry. Challenges include parental noncompliance (51%) and difficulty knowing when to stop the O2 (57%). CONCLUSIONS: Management of home O2 in patients with bronchiolitis is a common in UT and CO. Weaning practices vary. Further research is needed.

Treatment of skin and soft tissue infections in a pediatric observation unit.

OBJECTIVES: To report the success rate of observation unit (OU) treatment of pediatric skin and soft tissue infections (SSTIs) and to see if we could identify variables at the time of initial evaluation that predicted successful OU treatment. METHODS: A retrospective review of children less than 18 years of age admitted for SSTI treatment to our OU from the emergency department between January 2003 and June 2009. RESULTS: On records review, 853 patients matched eligibility criteria; median age was 5.2 years (interquartile range = 2.5-9 years). Of the 853 patients, 597 (70.0%) met the primary outcome criteria of successful OU discharge within 26 hours. Secondary analysis revealed that 82% of the patients achieved successful discharge from the OU within 48 hours. Although some laboratory variables demonstrated statistical association with success, none achieved a combination of high sensitivity and specificity to predict OU failure. OU success rates varied by location. Dental and face infections and those of the extremities or multiple sites demonstrated OU success rates higher than 65%, while infection of the groin, buttocks, trunk, or neck had success rates between 24% (neck) and 60% (groin). In multivariate analysis, only 3 variables remained significant. Unfavorable location was most strongly associated with OU failure, followed by C-reactive protein > 4 and then by erythrocyte sedimentation rate > 20. CONCLUSIONS: Our findings suggest that successful OU treatment is possible in a large group of patients needing hospitalization for SSTIs. Consideration of infection location may assist the emergency department clinician in determining the most appropriate unit for admission.

Decreasing hospital length of stay for bronchiolitis by using an observation unit and home oxygen therapy.

IMPORTANCE: Pediatric observation units (OUs) offer the opportunity to safely and efficiently care for common illnesses previously cared for in an inpatient setting. Home oxygen therapy (HOT) has been used to facilitate hospital discharge in patients with hypoxic bronchiolitis. It is unknown how implementation of a hospitalwide bronchiolitis treatment protocol promoting OU-HOT would affect hospital length of stay (LOS). OBJECTIVE: To test the hypothesis that using OU-HOT for bronchiolitis would decrease LOS. DESIGN AND SETTING: Retrospective cohort study at Primary Children's Medical Center, Salt Lake City, Utah. PARTICIPANTS: Uncomplicated bronchiolitis patients younger than 2 years admitted during the winter seasons of 2005 through 2011. INTERVENTIONS: Implementation of a new bronchiolitis care process encouraging use of an OU-HOT protocol. MAIN OUTCOME MEASURES: Mean hospital LOS, discharge within 24 hours, emergency department (ED) bronchiolitis admission rates and ED revisit/readmission rates, and inflation-adjusted cost. RESULTS: A total of 692 patients with bronchiolitis from the 2010-2011 bronchiolitis season were compared with 725 patients from the 2009-2010 season. Implementation of an OU-HOT protocol was associated with a 22.1% decrease in mean LOS (63.3 hours vs 49.3 hours, P < .001). Although LOS decreased during all 6 winter seasons, linear regression and linear quantile regression analyses for the 2005-2011 LOS data demonstrated a significant acceleration in the LOS decrease for the 2010-2011 season after implementation of the OU-HOT protocol. Discharges within 24 hours increased from 20.0% to 38.4% (P < .001), with no difference in ED bronchiolitis admission or ED revisit/readmission rates. After implementation of the OU-HOT protocol, the total cost per admitted case decreased by 25.4% ($4800 vs $3582, P < .001). CONCLUSIONS AND RELEVANCE: Implementation of an OU-HOT protocol for patients with bronchiolitis safely reduces hospital LOS with significant cost savings. Although widespread implementation has the potential for dramatic cost savings nationally, further studies assessing overall health care use and cost, including the impact on families and outpatient practices, are needed.

Outpatient management of patients with bronchiolitis discharged home on oxygen: a survey of general pediatricians.

OBJECTIVE: To describe the experience of general pediatricians in weaning bronchiolitis patients, treated as outpatients, from oxygen. METHODS: The authors surveyed members of the American Academy of Pediatrics' Council on Community Pediatrics regarding management of outpatient oxygen for bronchiolitis. RESULTS: The survey had 214 (28.4%) responses from pediatricians, of whom 172 (80.3%) practiced outpatient pediatrics. Among those, 27 (15.7%) cared for bronchiolitis patients discharged on oxygen. Pediatricians managing home oxygen practiced at higher altitude (5000 vs 339 ft, P < .001). No clear weaning protocol was reported. Over half (61.5%) of the pediatricians managing home oxygen acknowledged difficulty in deciding when to stop oxygen. A median of 2 (interquartile range [IQR] = 2-2) outpatient visits and 6 (IQR = 4-7) outpatient days on home oxygen were needed prior to oxygen discontinuation. CONCLUSION: Pediatricians are not routinely managing home oxygen for hypoxic bronchiolitis patients. Variable weaning process, difficulties in determining oxygen stoppage, multiple follow-up visits, and prolonged home oxygen usage highlight the need to evaluate the impact of this emerging practice.

Barriers to discharge from a 24-hour observation unit for children with bronchiolitis.

OBJECTIVES: The aim of this study was to determine physician-identified barriers to discharge of patients with bronchiolitis from a 24-hour emergency department-based observation unit. METHODS: Patients 3 to 24 months of age with a diagnosis of bronchiolitis were prospectively enrolled from January through April 2008. Patients were treated according to a standard hospital-wide bronchiolitis pathway that included an option for discharge on home oxygen. Treating physicians recorded barriers to discharge in those not sent home within 24 hours. The primary outcome was successful discharge within 24 hours; we analyzed barriers to such discharges. RESULTS: Fifty-five patients were enrolled in the study. Discharge within 24 hours failed in 30 patients (55%; 95% confidence interval [CI], 42%-67%). Among the 25 discharged patients, 6 (24%) went home on supplemental oxygen without adverse outcomes or readmission. Hypoxia was the most commonly identified barrier to discharge (n = 22, 73%). Of the 22 cases where hypoxia was a barrier, 18 (82%) also noted the need for deep nasal suctioning; 12 (55%), parental discomfort; 12 (55%), respiratory distress; 10 (46%), poor feeding; and 4 (18%), MD discomfort. CONCLUSIONS: Hypoxia was the most common barrier to discharge within 24 hours for patients with bronchiolitis, and a common cofactor when other barriers were identified. Research on home oxygen, the use of deep nasal suctioning, and parental discomfort with early discharge may be useful in reducing the need for inpatient care for bronchiolitis.