Epidemiology of immunoglobulin resistant Kawasaki disease: results from a large, national database.

Few data exist evaluating the epidemiology of Kawasaki disease (KD) resistant to intravenous immunoglobulin (IVIG) in the United States on a national level, and characterization of the epidemiology of IVIG resistance may improve patient care. We aim to characterize the incidence of KD resistant to IVIG therapy and risk factors for resistance in children's hospitals in the United States. A large, administrative database was used to identify pediatric patients admitted with an ICD-9 code for mucocutaneous lymph node syndrome (446.1) and a charge for at least one dose of IVIG. Patients were identified as resistant to IVIG therapy if there were ≥2 calendar days between an initial IVIG dose and a subsequent dose of IVIG, methylprednisolone, rituximab, or infliximab. Patient demographic and hospital information were collected, as well as the charges for imaging, laboratory, and medications. Resistance occurred in 16.3% (hospital range 8.0-26.8%) of the population and was not associated with time or number of patients admitted with KD. Patients admitted to hospitals in the highest quartile of resistance were more likely to be African-American (26.5 vs 20.1%, p < 0.01), less likely to have an echocardiogram performed (93.6 vs 97.1%, p < 0.01), were more likely to have a C-reactive protein drawn (93 vs 79.9%, p < 0.01), and were less likely to have an erythrocyte sedimentation rate drawn (87.9 vs 91.6%, p < 0.01). The incidence of KD resistant to IVIG is highly variable among pediatric hospitals and treatment patterns vary between hospitals with high- and low-resistance patterns. Further evaluation of diagnostic and treatment patterns at pediatric hospitals is warranted.

Sustained improvement in hand hygiene at a children's hospital.

A quality improvement project was conducted to improve hand hygiene at a children's hospital. Interventions included education, performance feedback, an incentive program, and a marketing campaign. There were 9,322 observations performed over a 5-year period. Hospital-wide adherence increased from 39.9% to 97.9%. Adherence of 95% or greater was sustained for over 3 years.

Emergency department crowding and analgesic delay in pediatric sickle cell pain crises.

OBJECTIVES: The objectives of the study were to test the impact of emergency department (ED) crowding and to identify factors associated with delay in analgesic administration in pediatric sickle cell pain crises. METHODS: This was a cross-sectional study at a children's hospital ED. Data included demographics, clinical features, triage acuity, 10-level triage pain score, and arrival-to-analgesic-administration time. Emergency department census was the crowding measure assigned to each patient at arrival. Severe pain was a triage pain score of more than 7. Delays of more than 60 minutes from arrival to analgesic administration represented poor care. Logistic regression tested the effect of ED census on time to analgesic administration after adjusting for patient demographic and clinical characteristics. RESULTS: From 243 encounters (161 patients), we excluded 11 visits (missing charts [n = 7], no pain at triage [n = 3], analgesic refusal [n = 1]). Final analysis involved 232 encounters (150 patients). Most were black with hemoglobin SS. Median age was 12 years. Mean ED census was 57. Median time from arrival to analgesic administration was 90 minutes. Analgesics were administered in less than 60 minutes in 70 encounters (30%). Most delays occurred after triage. Univariate analysis revealed that analgesic administration within 60 minutes of arrival was associated with severe pain at triage. After controlling for other factors, analgesic administration was significantly delayed during higher ED census and significantly earlier for young children and those with severe pain at triage. The time to analgesic administration from arrival significantly increased per increasing quartile of ED census (P = 0.0009). CONCLUSION: Emergency department crowding is associated with delay in analgesic administration in pediatric patients with sickle cell pain crisis.

Pediatric anxiety: child life intervention in day surgery.

Although many hospitals offer a surgical preparation program to children and families, minimal research has been conducted specifically on preparation by child life specialists. The purpose of this double-blind intervention study was to determine if children prepared for day surgery by a child life specialist exhibited less anxiety than those who received routine standard of care. One hundred forty-two children, aged between 5 and 11 years old, undergoing elective otolaryngology surgery completed the study. The "Child Drawing: Hospital" instrument developed by Clatworthy, Simon, and Tiedeman [Clatworthy, S., Simon, K., & Tiedeman, M. E. (1999). Child Drawing: Hospital - An instrument designed to measure the emotional status of hospitalized school-aged children. Journal of Pediatric Nursing, 14, 2-9] was used to determine children's anxiety levels preintervention and postintervention. Eighty children received formal preparation for their surgeries by a child life specialist and 62 received no intervention. The data were analyzed using a repeated-measures model with intervention, age, sex, and level of surgery for main effects. The anxiety score change was significantly better for the patients in the child life intervention group than for those in the nonintervention group, F(1,135) = 4.24, p = .04. The increase in anxiety scores in the nonintervention group suggests that children could benefit from preoperative preparation. Health professionals, including nurses, may impact children's abilities to cope with a surgical process. The information in this study will be useful in deciding whether all children, not just those with a perceived need, should be prepared prior to an elective day surgery.