Yes, we CAM: Increasing physician communication about complementary and alternative medicine through electronic medical record prompts in a pediatric hospital.

BACKGROUND AND PURPOSE: Over half of patients utilize complementary and alternative medicine (CAM), yet fewer than 10 % of physicians inquire about use. This prospective cohort study sought to increase patient-provider communication about CAM through electronic medical record (EMR) prompts and education, as well as study concordance rates of physician and nursing CAM-related documentation. MATERIALS AND METHODS: Recordings in history and physical (H&P) documents authored by first-year pediatric residents were used as a proxy for communication. Rates of documentation were assessed at baseline, after the introduction of an EMR prompt, and after an educational intervention. Nursing documentation was compared with resident documents to assess rates of concordance regarding CAM-related documentation. RESULTS: Baseline CAM-related documentation rate was 24 % and increased to 50 % after introducing an EMR CAM prompt (p < 0.001). No significant change occurred after education: 38 % had CAM-related documentation (p = 0.09). Physician and nursing documentation concordance rates were 58 % at baseline, 48 % after introduction of prompts, and 35 % after introducing education. CONCLUSION: Visual cues alone may be effective in increasing patient-provider communication about CAM, though low concordance between physician and nursing documentation may suggest variability in how CAM is defined and inquired about.

A pilot project: handwashing educational intervention decreases incidence of respiratory and diarrheal illnesses in a rural Malawi orphanage.

Children who live in orphanages represent a population particularly vulnerable to transmissible diseases. Handwashing interventions have proven efficacy for reducing the rate of transmission of common infectious diseases. Few studies have analyzed the delivery of health interventions for children in orphanages in sub-Saharan Africa. To address this gap, we conducted an ecological assessment and piloted a handwashing intervention in an orphanage in rural Malawi, focusing on caregiver knowledge and behaviors, child handwashing behaviors, and disease incidence. A secondary study aim was to demonstrate program feasibility for a future randomized controlled trial. Orphanage caregivers participated in a three-module educational intervention on handwashing based on WHO recommendations and workshops on how to teach the curriculum to children. Seventeen orphanage caregivers and 65 children were monitored for handwashing behavior and child disease incidence. Friedman's tests were conducted to compare changes in caregiver knowledge and behaviors. Child handwashing behaviors and surveillance of child disease incidence were measured pre- and post-intervention. There were significant increases in caregiver hand hygiene knowledge. At six months post-intervention, handwashing with soap increased significantly among caregivers (p < 0.001) and was observed in children. The incidence of acute respiratory infections decreased from 30% to 6% post-intervention, resulting in an 80% decrease. The incidence of diarrhea decreased from 9.2% to 6.2% post-intervention, resulting in a 33% decrease. A brief educational intervention may improve handwashing knowledge and behaviors and help to decrease the incidence of common infectious diseases in an orphanage in rural Malawi. In addition, the caregiver uptake of the intervention demonstrated feasibility for future studies.

Epidemiology of Cerebrospinal Fluid Cultures and Time to Detection in Term Infants.

BACKGROUND: Although meningitis is rare in previously healthy term infants, lumbar puncture is often performed to evaluate for source of illness. This study was performed to determine the time to detection for positive cerebrospinal fluid (CSF) cultures and to provide an update on the current epidemiology of bacterial meningitis in term infants. METHODS: This study was a multicenter, retrospective review of positive CSF cultures in infants ≤90 days of age. Specimens were drawn in the emergency department or inpatient setting between January 2000 and December 2013. Cultures were deemed true pathogens or contaminant species based on the attending physician's treatment plan. Cultures from premature infants, an operative source, or those with significant medical history were excluded. RESULTS: A total of 410 positive CSF culture results were included, with 53 (12.9%) true pathogens and 357 (87.1%) contaminant species. The mean ± SD time to detection for true pathogens was 28.6 ± 16.8 hours (95% confidence interval, 24-33.2); for contaminant species, it was 68.1 ± 36.2 hours (95% confidence interval, 64.3-71.9). Forty-three true-positive cases (81.1%) were positive in ≤36 hours. The most common pathogen was group B Streptococcus (51%), followed by Escherichia coli (13%) and Streptococcus pneumoniae (9%). CONCLUSIONS: The majority of pathogenic bacteria in CSF exhibit growth within 36 hours. Most growth from CSF cultures in febrile infants is treated as contamination. The epidemiology of meningitis has remained constant, with group B Streptococcus as the predominant pathogen, despite changes noted in the epidemiology of bacteremia in this population.

Association between pediatric home management plan of care compliance and asthma readmission.

OBJECTIVES: In 2007, The Joint Commission implemented three children's asthma care (CAC) measures to help improve the quality of care for patients admitted with asthma. Due to lack of consistent evidence showing a relationship between home management plan of care (HMPC) compliance and readmission rates, CAC-3 was retired in 2016. We aimed to understand the relationship between HMPC compliance and revisits to the hospital, and investigate which components of the HMPC, if any, were driving the effect. METHODS: This was a retrospective cohort study at a quaternary care freestanding children's hospital, including patients between 2 and 17 years of age admitted with a primary diagnosis of asthma between January 1, 2006, and July 1, 2013. Bivariate and multiple logistic regression analyses examined effects of HMPC provider compliance on hospital readmission and emergency department utilization for asthma within 180 days of initial discharge, controlling for admission to the intensive care unit, age, gender, ethnicity, insurance type, and whether inhaled corticosteroids were prescribed. RESULTS: A total of 1,176 patients were included. Those discharged with an HMPC (n = 756, of which 84% were fully compliant) were found to have significantly lower readmission rates (7 vs. 11.9%; aOR = 0.63; 95% CI, 0.41-0.95) and ED revisit rates (aOR = 0.73; 95% CI, 0.56-0.96) within 180 days of discharge. CONCLUSIONS: Providing an HMPC upon discharge was found to be associated with decreased asthma readmission and ED utilization rates. This suggests that although HMPC is no longer a required measure, there may still be utility in continuing this practice.

Association Between Implementation of a Cardiovascular Step-Down Unit and Process-of-Care Outcomes in Patients With Congenital Heart Disease.

BACKGROUND: The Joint Commission's 2009 National Patient Safety Goals aimed to improve identification of and response to clinical deterioration in hospital-ward patients. Some hospitals implemented intermediate-care units for patients without intensive care-level support needs. No studies have evaluated what effect changes associated with a move to a pediatric cardiovascular step-down unit (CVSDU) has on process-of-care outcomes. METHODS: A retrospective cohort study comparing process-of-care outcomes in units caring for children with congenital heart disease (n=1415) 1 year before (July 1, 2010-June 30, 2011) and 1 year after (August 1, 2011-July 30, 2012) implementation of a CVSDU following the move to a new hospital building. Units caring for noncardiac tracheostomy and/or ventilator-dependent patients were used as controls (n=606). Primary outcomes included length of stay (LOS) and transfers to higher levels of care. Secondary outcomes included rapid response team, cardiopulmonary arrest, and code blue rates. Mann-Whitney U and z tests were used for all analyses. RESULTS: When compared with a medical-surgical unit, cardiac patients admitted to a CVSDU had a significantly decreased total LOS (median 7.0 vs 5.4 days, P=.03), non-ICU LOS (median 3.5 vs 3.0 days, P=.006), and rapid response team/code blue rate per 1000 non-ICU patient days (11.2 vs 7.0, P=.04). No significant differences in primary or secondary outcomes were seen within the control group. CONCLUSIONS: Changes associated with a new CVSDU were associated with decreased LOS and lower rates of rapid response and code blue events for patients with congenital heart disease.

Improving home management plan of care compliance rates through an electronic asthma action plan.

BACKGROUND: In 2007, the Joint Commission mandated reporting of three children's asthma care (CAC) measures for hospitalized patients with asthma. The third children's asthma care measure (CAC-3) focuses on hospital discharge with a comprehensive home management plan of care (HMPC) based on the clinical severity. OBJECTIVE: To improve CAC-3 compliance and identify what interventions would have the most impact. METHODS: This was a retrospective observational study, conducted at the Children's Hospital Los Angeles (CHLA) between October 2008 and January 2012. A total of 470 patients admitted with a primary diagnosis of asthma were included. Four Plan-Do-Study-Act cycles testing separate interventions were used throughout the study period: clinical care coordinators (CCCs), red clipboard for paper HMPC, electronic HMPC, and hard-stop HMPC. Chi-square and binomial tests compared CHLA's CAC-3 compliance rates within intervention windows as well as to the national average. RESULTS: Between October 2008 and May 2009, CHLA had a compliance rate of 39%, well below the national average (p = .001). Involvement of CCCs increased the overall compliance to 74% (χ(2)(1) = 11.59, p < .001). Implementation of an electronic HMPC in October 2010 led to the largest increase in overall compliance (93%) when compared to the previous intervention window (χ(2)(1) = 4.38, p < .036), as well as the national average (p = .016). Compliance rates remained above 90% for four out of the following five quarters. CONCLUSIONS: Involvement of CCCs led to a significant increase in the overall CAC-3 compliance. An electronic HMPC improved rates well above the national average. This provides a framework for other institutions that may or may not utilize an electronic medical record.

A 3-month-old infant with upper extremity weakness.

A detailed history should be obtained for all pediatric patients presenting with acute neurological changes. A thorough physical exam can help narrow the possible etiologies. Prompt imaging can lead to a more precise understanding of the level of neuronal involvement. Neurenteric cysts and fistulas are extremely rare in the pediatric population, with most occurring in the lower cervical and upper thoracic region. Most patients will present with symptoms related to cord or brainstem compression; however, associated infections have been reported. Epidural abscesses are also rare, occurring in the mid-thoracic or lower lumbar region. When there is no communication between the gastrointestinal tract and spinal canal, S. aureus accounts for most of these infections. When gram-negative pathogens, such as E.coli and E. cloacae, are isolated, it is imperative to evaluate for the presence of neurenteric fistulas. Because of numerous anomalies associated with neurenteric cysts, the entire spinal canal should be evaluated completely.

Identification of truncated form of mouse HAX-1s gene (HAX-1xs) and characterization of its expression in small intestine and thymus of mice after burn injury.

Burn injury often leads to distant organ injury such as acute respiratory distress syndrome. We hypothesize that the pathophysiologic changes in distant organs result from orchestrated regulation of multiple genes in response to bum injury. Differential display was performed to identify genes regulated in distant organs in response to burn injury. Initial characterization of differentially amplified products demonstrated that HAX-1s mRNA was regulated in several distant organs after 18% total body surface area (TBSA) full-thickness flame burn injury in mice. Further characterization of HAX-1s mRNA revealed a novel transcript variant, which is rapidly and transiently induced in multiple tissues of mice within 6 h after burn injury. This novel HAX-1s transcript variant, called HAX-1xs, has an internal deletion of 252 nucleotides and single point mutation, resulting in reading frame intact. Western blot and immunohistochemical analyses of multiple tissues of mice using rabbit antibody raised against a 15-mer synthetic peptide clearly revealed the presence of HAX-1xs protein in the duodenum, and suggested that expression of HAX-1xs and/or HAX-1s was tissue- and cell type-specific. The expression of HAX-1xs and/or HAX-1s was distinctively regulated in Paneth cells of the duodenum and macrophages of the thymus after burn injury. These findings suggest that HAX-1xs has a different biological activity from HAX-1s and participates in a cascade of immediate-early cellular events in response to burn injury.