Improving a Urine Culture Callback Follow-up System in a Pediatric Emergency Department.

INTRODUCTION: Delays in appropriate treatment and unnecessary antibiotic use for urinary tract infections (UTIs) increase the risk for serious adverse events and the potential for antibiotic resistance. The purposes of this quality improvement project were to decrease emergency department laboratory result follow-up time and increase the number of patients who are notified to stop taking an empiric antibiotic. METHOD: Nine months of Plan-Do-Study-Act (PDSA) cycles were implemented in a pediatric emergency department and network of care sites. Three months of baseline data were compared with 3 months of postinvention data using t-tests and odds ratios. RESULTS: Time to patient/family laboratory follow-up was reduced from 20.1 hours to 7.1 hours, demonstrating a 64.7% reduction in time to follow-up (p < .01). The percentage of patients who received follow-up notification of negative urine cultures and were told to discontinue antibiotic therapy increased from 8.8% to 74.4% (p < .001). DISCUSSION: Implementation of a culture callback system, staffed by advanced practice providers, led to a significant reduction in the amount of time to follow-up and increased the number of follow-up calls to discontinue antibiotics when urine cultures were negative.

Junglemobile: a mobile injury-prevention program for young children.

OBJECTIVE: To evaluate the child passenger safety curriculum of the Junglemobile, a traveling injury prevention program for young children. DESIGN: Cross-sectional evaluation with self-controls, convenience sample. SETTING: School and community events in rural Colorado, Wyoming, and western Nebraska where the Junglemobile participated for the years 2000-2003. PARTICIPANTS: Children 11 years of age or younger attending a Junglemobile event. INTERVENTION: Children were tested on the Junglemobile child passenger safety curriculum. Children 3 to 6 years of age (Group 1) completed a pretest and a posttest. Children 7 to 11 years of age (Group 2) completed a pretest, an immediate posttest, and a 30-day posttest. RESULTS: Two hundred thirty-seven children in Group 1 completed the pretest, 76% completed both tests. In Group 2, 420 children took the pretest, 55% took all the 3 tests. Group 1 showed significant improvement in the ability to demonstrate the appropriate place to ride in a car, t (179) = -4.06, P < .001. In Group 2, 61% reported always being restrained on the pretest and 73.2% on the 30-day posttest, t(230) = -3.85, P < .001; 85.7% reported being restrained the last time they rode in a car or truck on the pretest; and 93.5% on the 30-day posttest t(228) = -3.38, P < .001. Reported booster seat use increased on 30-day posttest and was greater when parents received an educational brochure (increased approximately 5% without brochure vs 25% with brochure). CONCLUSIONS: Children can be taught about child passenger safety through the Junglemobile, a simple educational strategy. Parental education significantly modifies booster seat use.

The lack of motor vehicle occupant restraint use in children arriving at school.

BACKGROUND: Motor vehicle crashes are the leading cause of mortality for children aged 4-14 in the United States. Many children are driven daily to school, increasing their exposure to potential injury, especially if they are not appropriately restrained. Observing the level of motor vehicle occupant restraint (MVOR) use upon school arrival could lead to valuable information for the development of an injury prevention program targeted to this population. This study compares the rate of MVOR use upon arrival to elementary schools with that at regional intersections. METHODS: One hundred thirty-five census tracts in the Denver, Colorado, area were identified and combined into 5 regions. Within each region, 1 controlled intersection and 1 elementary school were observed. Observations were conducted for 1 hour at each of these locations. RESULTS: At intersections, 618 children in private vehicles were observed. MVOR use rate was 71.2% (440/618). At schools, 665 children in private vehicles were observed. MVOR use was 24.8% (165/665). Children arriving at school were less likely to be restrained than those observed at intersections (relative risk: 0.35, 95% CI: 0.30-0.40). CONCLUSIONS: Children at elementary schools showed substantially lower MVOR use rates than those observed at controlled intersections. Further investigation is imperative to determine the reason behind the low use of MVOR in children being transported to school. Based on the reasons elicited, interventions emphasizing the importance of always using MVOR can be developed and tailored to meet the educational needs of parents transporting their children to school in private vehicles.

Collaborative Approaches to e-Health: Valuable for Users and Non-users.

OBJECTIVE: To describe parental use of an Internet-based educational and emotional support system, in a regional NICU program. METHODS: Baby CareLink was installed in NICUs in 4 Denver area hospitals in 2003. Parents were offered access from hospital terminals and from any other Internet access point. Data on use of the program was collected by the computer system. Discharge status was verified by Colorado's Department of Public Assistance. RESULTS: Of the 388 families admitted to Denver area NICUs with Baby CareLink during the study period, 135 (34.8%) were identified as Medicaid families (needing public assistance). After exclusions, data for 81 Medicaid and 154 non-Medicaid families were available for analysis. Medicaid families who accessed 3 or more Baby CareLink web pages per day took their infants home 17.5 days sooner than families who used Baby CareLink less often (p=0.03). Among the non-Medicaid families, more frequent users of Baby CareLink took their infants home 14.3 days sooner (p=0.04). CONCLUSIONS: Internet portals will be used by both Medicaid and non-Medicaid parents with children in NICUs to meet educational needs. More frequent use of Baby CareLink was associated with significantly shorter length of stay. Self-help tools for parents may free nursing resource for families with greater needs.

Childhood femur fractures, associated injuries, and sociodemographic risk factors: a population-based study.

OBJECTIVE: The objectives of this study were to determine the incidence of femur fractures in Colorado children, to assess underlying causes, to determine the prevalence and predictors of associated injuries, and to identify potentially modifiable risk factors. METHODS: The study population included all Colorado residents who were aged 0 to 17 years at the time of injury between January 1, 1998, and December 31, 2001. Cases of femur fracture were ascertained using the population-based Colorado Trauma Registry and International Classification of Diseases, Ninth Revision, Clinical Modification codes 820.0 to 821.39. Associated injuries with an Abbreviated Injury Scale of 2 or higher were classified into 5 categories. Poisson regression, small area analysis, and multivariate logistic regression were used to identify predictors of femur fractures and associated injuries, respectively. RESULTS: During the study period, 1139 Colorado children (795 boys, 344 girls) sustained femur fractures, resulting in the incidence of 26.0 per 100000 person-years. Rates were higher in boys than in girls in all age groups (overall risk ratio: 2.19; 95% confidence interval: 1.92-2.47) but did not differ by race/ethnicity. Femur fractures that were caused by nonaccidental trauma showed more distal and combined shaft + distal pattern; their incidence did not differ by gender or race but was higher in census tracts with more single mothers and less crowded households. Associated injuries were present in 28.6% of the cases, more often in older children. Fatalities occurred only among children with associated injuries. Children who were involved in nonaccidental trauma, motor vehicle crashes, or auto-pedestrian accidents were 16 to 20 times more likely to have associated injuries than those with femur fractures as a result of a fall. In small-area analysis, the incidence of femur fractures in infants and toddlers was higher in census tracts characterized by higher proportion of Hispanics, single mothers, and more crowded households. Among children 4 to 12 years of age, the incidence was higher in census tracts with fewer single-family houses and more crowded households. Finally, the incidence of femur fractures among teenagers was higher in rural tracts and those with a higher proportion of Hispanics. CONCLUSIONS: Femur fractures and associated injuries remain a major cause of morbidity in children. Predictors of femur fractures change with age; however, the risk is generally higher among children who live in the areas with lower socioeconomic indicators.

A Medicaid eHealth program: an analysis of benefits to users and nonusers.

OBJECTIVE: To describe parental use of an Internet-based educational and emotional support system, in a regional NICU program. METHODS: Baby CareLink was installed in NICUs in 4 Denver area hospitals in 2003. Parents were offered access from hospital terminals and from any other Internet access point. Data on use of the program was collected by the computer system. Discharge status was verified by Colorado's Department of Public Assistance. RESULTS: Of the 388 families admitted to Denver area NICUs with Baby CareLink during the study period, 135 (34.8%) were identified as Medicaid families (needing public assistance). After exclusions, data for 81 Medicaid and 154 non-Medicaid families were available for analysis. Medicaid families who accessed 3 or more Baby CareLink web pages per day took their infants home 17.5 days sooner than families who used Baby CareLink less often (p=0.03). Among the non-Medicaid families, more frequent users of Baby CareLink took their infants home 14.3 days sooner (p=0.04). CONCLUSIONS: Internet portals will be used by both Medicaid and non-Medicaid parents with children in NICUs to meet educational needs. More frequent use of Baby CareLink was associated with significantly shorter length of stay. Self-help tools for parents may free nursing resource for families with greater needs.

Resistance to antimalarials in Southeast Asia and genetic polymorphisms in pfmdr1.

Resistance to antimalarial drugs is a public health problem worldwide. Molecular markers for drug-resistant malaria, such as pfcrt and pfmdr1 polymorphisms, could serve as useful surveillance tools. To evaluate this possibility, sequence polymorphisms in pfcrt (position 76) and pfmdr1 (positions 86, 184, 1034, 1042, and 1246) and in vitro drug sensitivities were measured for 65 Plasmodium falciparum isolates from Thailand, Myanmar, Vietnam, and Bangladesh. The pfcrt Thr76 polymorphism was present in 97% of samples, consistent with observations that chloroquine resistance is well established in this region. Polymorphisms in pfmdr1 clustered into four specific patterns: the wild type (category I), a Tyr86 polymorphism only (category II), a Phe184 polymorphism only (category III), and Phe184 in combination with Cys1034 and/or Asp1042 (category IV). Isolates in categories I and III were more sensitive to chloroquine and more resistant to mefloquine, artesunate, and artemisinin than isolates in categories II and IV (P /=3. The isolates in all 8 samples fell into categories I and III and were significantly more resistant to mefloquine, quinine, artemisinin, and artesunate and more sensitive to chloroquine than the isolates in the 57 samples with <3 copies of the gene (P

Recrudescence in artesunate-treated patients with falciparum malaria is dependent on parasite burden not on parasite factors.

Artemisinin derivatives are first-line antimalarial drugs in Thailand. No firm evidence of clinically relevant artemisinin resistance exists. When used as monotherapy, artesunate has been associated with a high treatment failure (recrudescence) rate, which could be due to low-level artemisinin resistance. To understand the causes of recrudescence, we retrospectively studied a cohort of 104 malaria patients treated with artesunate monotherapy, 32 of whom recrudesced. There was no difference in in vitro artesunate sensitivities between 6 nonrecrudescent isolates and 16 paired admission and recrudescent isolates. Paired admission and recrudescent isolates from 10 patients were genotyped; only 3 had pfmdr1 mutations. Patients with admission parasitemias >10,000 per microl had a 9-fold higher likelihood of recrudescence (adjusted odds ratio) compared with patients with lower parasitemias. This study suggests (1) recrudescence after treatment with artesunate is not the result of inherent parasite resistance, and (2) admission parasitemia may be useful in choosing therapeutic options.

Utility of whole blood hemostatometry using the clot signature analyzer for assessment of hemostasis in cardiac surgery.

BACKGROUND: A hemostatic monitor capable of rapid, accurate detection of clinical coagulopathy within the operating room could improve management of bleeding after cardiopulmonary bypass (CPB). The Clot Signature Analyzer is a hemostatometer that measures global hemostasis in whole blood. The authors hypothesized that point-of-care hemostatometry could detect a clinical coagulopathic state in cardiac surgical patients. METHODS: Fifty-seven adult patients scheduled for a variety of elective cardiac surgical procedures were studied. Anesthesia, CPB, heparin anticoagulation, protamine reversal, and transfusion for post-CPB bleeding were all managed by standardized protocol. Clinical coagulopathy was defined by the need for platelet or fresh frozen plasma transfusion. The Clot Signature Analyzer collagen-induced thrombus formation (CITF) assay measured platelet-mediated hemostasis in vitro. The activated clotting time, platelet count, prothrombin time, activated partial thromboplastin time, and fibrinogen concentration were also measured. RESULTS: The postprotamine CITF was greater in patients who required hemostatic transfusion than in those who did not (17.6 +/- 8.0 min vs. 10.5 +/- 5.7 min, respectively; P < 0.01). Postprotamine CITF values were highly correlated with platelet and fresh frozen plasma transfusion (Spearman r = 0.50, P < 0.001 and r = 0.40, P < 0.005, respectively). Receiver operator characteristic curves showed a highly significant relation between the postprotamine CITF and intraoperative platelet and fresh frozen plasma transfusion (area under the curve, 0.78-0.81, P < 0.005) with 60-80% sensitivity, specificity, positive and negative predictive values at cutoffs of 12-14 min. Logistic regression demonstrated that the CITF was independently predictive of post-CPB hemostatic transfusion, but standard hemostatic assays were not. CONCLUSIONS: The Clot Signature Analyzer CITF detects a clinical coagulopathic state after CPB and is independently predictive of the need for hemostatic transfusion. Hemostatometry has potential utility for monitoring hemostasis in cardiac surgery.