Adverse Safety Events in Emergency Medical Services Care of Children With Out-of-Hospital Cardiac Arrest.

Importance: Survival for children with out-of-hospital cardiac arrest (OHCA) remains poor despite improvements in adult OHCA survival. Objective: To characterize the frequency of and factors associated with adverse safety events (ASEs) in pediatric OHCA. Design, Setting, and Participants: This population-based retrospective cohort study examined patient care reports from 51 emergency medical services (EMS) agencies in California, Georgia, Oregon, Pennsylvania, Texas, and Wisconsin for children younger than 18 years with an OHCA in which resuscitation was attempted by EMS personnel between 2013 and 2019. Medical record review was conducted from January 2019 to April 2022 and data analysis from October 2022 to February 2023. Main Outcomes and Measure: Severe ASEs during the patient encounter (eg, failure to give an indicated medication, 10-fold medication overdose). Results: A total of 1019 encounters of EMS-treated pediatric OHCA were evaluated; 465 patients (46%) were younger than 12 months. At least 1 severe ASE occurred in 610 patients (60%), and 310 patients (30%) had 2 or more. Neonates had the highest frequency of ASEs. The most common severe ASEs involved epinephrine administration (332 [30%]), vascular access (212 [19%]), and ventilation (160 [14%]). In multivariable logistic regression, the only factor associated with severe ASEs was young age. Neonates with birth-related and non-birth-related OHCA had greater odds of a severe ASE compared with adolescents (birth-related: odds ratio [OR], 7.0; 95% CI, 3.1-16.1; non-birth-related: OR, 3.4; 95% CI, 1.2-9.6). Conclusions and Relevance: In this large geographically diverse cohort of children with EMS-treated OHCA, 60% of all patients experienced at least 1 severe ASE. The odds of a severe ASE were higher for neonates than adolescents and even higher when the cardiac arrest was birth related. Given the national increase in out-of-hospital births and ongoing poor outcomes of OHCA in young children, these findings represent an urgent call to action to improve care delivery and training for this population.

Using Two Statewide Medical Operations Coordination Centers to Load Balance in Pediatric Hospitals During a Severe Respiratory Surge in the United States.

OBJECTIVES: Report on the use of two statewide Medical Operations Coordination Centers (MOCCs) to manage a rapid surge in pediatric acute and critical care patient needs. DESIGN: Brief report. SETTING: The states of Washington and Oregon during the pediatric respiratory surge in November 2022/December 2022 which overwhelmed existing pediatric acute and critical care hospital capacity. PATIENTS: Pediatric patients requiring hospitalization in Washington and Oregon. INTERVENTIONS: Adaptations to the use of two existing statewide MOCCs to provide pediatric patient load balancing through surveillance, modifications of existing referral agreements, coordinated expansion of resources, activation of regional crisis standards of care, and integration of pediatric critical care physicians from Harborview Medical Center as subject matter experts (SMEs). MEASUREMENTS AND MAIN RESULTS: The Washington and Oregon MOCCs managed 183 pediatric requests from hospitals unable to transfer pediatric patients between November 1, 2022, and December 14, 2022. Sixteen percent of requests were for children younger than 3 months and 37% were for children between 3 months and 1 year; most had acute viral respiratory disease. Requests for children older than 13 years old were primarily intentional drug ingestions. Fifty-eight percent were for critically ill children and 17% originated from critical access hospitals. Washington's SMEs were utilized in nearly a quarter of cases with the disposition changing in 38% of these. CONCLUSIONS: Washington and Oregon statewide MOCCs have leveraged centralized coordination to effectively load balance a surge in pediatric patients which has overwhelmed existing pediatric hospital resources. Centralized coordination and surveillance informed pediatric hospitals and policy makers of unmet clinical needs and facilitated rapid expansion of clinical capacity and modifications to referral processes. Integration of pediatric SMEs enabled efficient triage of these resources. MOCCs provide an adaptable centralized resource for addressing surge and have been effective in managing overwhelmed pediatric hospital resources in Washington and Oregon.

A chart review tool to systematically assess the safety of prehospital care for children with out-of-hospital cardiac arrest.

Objective: Create an easy-to-use pediatric out-of-hospital cardiac arrest (OHCA)-specific chart review tool to reliably detect severe adverse safety events (ASEs) in the prehospital care of children with OHCA. Methods: We revised our previously validated pediatric prehospital adverse event detection system (PEDS) tool, used to evaluate ASEs in the prehospital care of children during emergent calls, to create an OHCA-specific chart review tool. We developed decision support for reviewers, reviewer training, and a dedicated section for chart data abstraction. We randomly selected 28 charts for independent review by 2 expert reviewers who determined the presence or absence of a severe ASE for each care episode and identified the domain of care and preventability for each ASE. We calculated inter-rater agreement in the assessment of the presence or absence of a severe ASE using Gwet's first-order agreement coefficient (AC1). Results: The PEDS-OHCA chart review tool has 6 sections, with a minimum of 70 and maximum of 667 total possible fields. We found inter-rater agreement of 0.83 (95% confidence interval, 0.63-0.99) between our 2 reviewers for the overall detection of a severe ASE and an average time to complete of 8 minutes (range, 2-25 minutes). Inter-rater agreement in the detection of a severe ASE in each individual domain ranged from 0.36 to 0.96. Conclusions: The PEDS-OHCA is the first chart review tool to systematically evaluate the safety and quality of EMS care for children with OHCA. This tool may help improve understanding of the quality of EMS care for children with OHCA, which is essential to improving outcomes.

Universal Level Designations for Hospitalized Pediatric Patients in Evacuation.

Children comprise approximately 22% of the population in the United States.1 In a widespread disaster such as a hurricane, pandemic, wildfire or major earthquake, children are at least proportionately affected to their share of the population, if not more so. They also have unique vulnerabilities including physical, mental, and developmental differences from adults, which make them more prone to adverse health effects of disasters.2-4 There are about 5000 pediatric critical care beds and 23 000 neonatal intensive care beds out of 900 000 total hospital beds in the United States.5 While no mechanism exists to consistently track pediatric acute care beds nationally (especially in real time), a previous study6 showed a 7% decline in pediatric medical-surgical beds between 2002 and 2011. This study also estimated there are about 30 000 acute care pediatric beds nationally. Finding appropriate hospital resources for the provision of care for pediatric disaster victims is an important concern for those charged with triaging patients in a major event.

Hospital Mortality and Functional Outcomes in Pediatric Neurocritical Care.

OBJECTIVES: Pediatric neurocritical care (PNCC) outcomes research is scarce. We aimed to expand knowledge about outcomes in PNCC by evaluating death and changes in Functional Status Scale (FSS) from baseline among PNCC diagnoses. METHODS: We conducted a 2-year observational study of children aged 0 to 18 years admitted to the ICU with a primary neurologic diagnosis (N = 325). Primary outcomes were death and change in FSS from preadmission baseline to discharge. New disability was defined as an FSS change of ≥1 from baseline, and severe disability was defined as an FSS change of ≥3. Categorical results are reported as relative risk (RR) with 95% confidence interval (CI). RESULTS: Thirty (9%) patients died. New disability (n = 103; 35%) and severe disability (n = 37; 13%) were common in PNCC survivors. New disability (range 14%-54%) and severe disability (range 3%-33%) outcomes varied significantly among primary diagnoses (lowest in status epilepticus; highest in infectious and/or inflammatory and stroke cohorts). Disability occurred in all FSS domains: mental status (15%), sensory (52%), communication (38%), motor (48%), feeding (40%), and respiratory (12%). Most (64%) patients with severe disability had changes in ≥3 domains. Requiring critical care interventions (RR 2.1; 95% CI 1.5-3.1) and having seizures (RR 1.5; 95% CI 1.1-2.0) during hospitalization were associated with new disability. CONCLUSIONS: PNCC patients have high rates of death and new disability at discharge, varying significantly between PNCC diagnoses. Multiple domains of disability are affected, underscoring the ongoing multidisciplinary health care needs of survivors. Our study quantified hospital outcomes of PNCC patients that can be used to advance future research in this vulnerable population.

The Burden of Pediatric Neurocritical Care in the United States.

BACKGROUND: Disorders requiring pediatric neurocritical care (PNCC) affect thousands of children annually. We aimed to quantify the burden of PNCC through generation of national estimates of disease incidence, utilization of critical care interventions (CCI), and hospital outcomes. METHODS: We performed a retrospective cohort analysis of the Kids Inpatient Database over three years to evaluate pediatric traumatic brain injury, neuro-infection or inflammatory diseases, status epilepticus, stroke, hypoxic ischemic injury after cardiac arrest, and spinal cord injury. We evaluated use of CCI, death, length of stay, hospital charges, and poor functional outcome defined as receipt of tracheostomy or gastrostomy or discharge to a medical care facility. RESULTS: At least one CCI was recorded in 67,058 (23%) children with a primary neurological diagnosis, and considered a PNCC admission. Over half of PNCC admissions had at least one chronic condition, and 23% were treated in children's hospitals. Mechanical ventilation was the most common CCI, but utilization of CCIs varied significantly by diagnosis. Among PNCC admissions, 8110 (12%) children died during hospitalization and 14,067 (21%) children had poor functional outcomes. PNCC admissions cumulatively accounted for over 1.5 million hospital days and over $4 billion in hospital costs in the study years. Most PNCC admissions, across all diagnoses, had prolonged hospitalizations (more than one week) with an average cost of $39.9 thousand per admission. CONCLUSIONS: This large, nationally representative study shows PNCC diseases are a significant public health burden with substantial risk to children's health. More research is needed to improve outcomes in these vulnerable children.

Reliability and Usability of a 7-Minute Chart Review Tool to Identify Pediatric Prehospital Adverse Safety Events.

BACKGROUND AND OBJECTIVES: Although medical errors in the hospital are a recognized source of morbidity and mortality, less is known about safety events in the prehospital care of children. As part of a multiphase study, we developed and evaluated the reliability and usability of the pediatric prehospital safety event detection system (PEDS), a tool used to identify safety events in prehospital care. METHODS: The tool was based on hospital chart review tools, literature review, and results from focus groups and a national Delphi survey. After reviewer training, preliminary testing, and initial use, we refined the tool on the basis of data analysis and reviewer feedback. Thirty charts were randomly selected from our study population of pediatric transports with lights and sirens in Multnomah County, Oregon, and independently reviewed by 2 pediatric emergency physicians with experience in prehospital care to evaluate interrater reliability and time to completion of the final tool. RESULTS: The PEDS tool contains 36 items, takes reviewers a median of 7 minutes to complete (interquartile range: 4-12), and exists in both paper and electronic formats. When comparing the presence or absence of severe safety events between 2 expert arbiters, we found 87% agreement (κ = 0.68), indicating good agreement. CONCLUSIONS: The PEDS tool is the first chart review tool designed to identify safety events for children receiving prehospital care, and it displayed good usability and reliability in this study. With this tool, we provide a novel mechanism for researchers, clinicians, and prehospital care leaders to identify opportunities to improve care for children.

Endovascular Therapy in Pediatric Stroke: Utilization, Patient Characteristics, and Outcomes.

BACKGROUND AND PURPOSE: Despite strong evidence for endovascular therapy in adults with acute arterial ischemic stroke, limited data exist in children. We aimed to describe endovascular therapy utilization and explore outcomes in a national sample of pediatric arterial ischemic stroke. METHODS: We queried the 2012 Kids' Inpatient Database for children aged greater than 28 days to 20 years with the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for arterial ischemic stroke and evaluated groups based on the procedure code for endovascular therapy. Poor outcome was defined as need for tracheostomy or gastrostomy, discharge to rehabilitation facility, or death. Logistic regression evaluated the association between endovascular therapy and poor outcome, adjusted for age, disease severity (hemiplegia, critical care interventions, neurosurgical interventions), and comorbidities. RESULTS: We identified 3184 pediatric discharges with a diagnosis code for arterial ischemic stroke. Thirty-eight (1%) had an endovascular therapy procedure code. Endovascular therapy patients were older (10.2 versus 4.5 years, P < 0.001) and more likely to have hemiplegia/paresis (relative risk [RR] 3.8, 95% confidence interval [CI] 2.0-7.4), aphasia (RR 5.3, 95% CI 2.8-10.1), and facial droop (RR 4.0, 95% CI 1.9-8.7). Endovascular therapy was not associated with critical care and neurosurgical interventions or intracranial hemorrhage. Length of hospitalization, mortality, and discharge disposition were similar between groups. In a multivariable model, endovascular therapy was not associated with poor outcome (adjusted odds ratio 1.7, 95%, CI 0.7-4.1). CONCLUSIONS: In a national sample of children with a diagnosis of arterial ischemic stroke, endovascular therapy was infrequently utilized. Patients with a procedure code for endovascular therapy had significant stroke-related deficits, but outcomes were similar to those in children who did not receive endovascular therapy. Our data, in conjunction with evidence of benefit in adults, support consideration of endovascular therapy for select children with acute stroke.

The Association Between Hospital Capacity Strain and Inpatient Outcomes in Highly Developed Countries: A Systematic Review.

BACKGROUND: Increases in patient needs can strain hospital resources, which may worsen care quality and outcomes. This systematic literature review sought to understand whether hospital capacity strain is associated with worse health outcomes for hospitalized patients and to evaluate benefits and harms of health system interventions to improve care quality during times of hospital capacity strain. METHODS: Parallel searches were conducted in MEDLINE, CINAHL, the Cochrane Library, and reference lists from 1999-2015. Two reviewers assessed study eligibility. We included English-language studies describing the association between capacity strain (high census, acuity, turnover, or an indirect measure of strain such as delayed admission) and health outcomes or intermediate outcomes for children and adults hospitalized in highly developed countries. We also included studies of health system interventions to improve care during times of capacity strain. Two reviewers extracted data and assessed risk of bias using the Newcastle-Ottawa Score for observational studies and the Cochrane Collaboration Risk of Bias Assessment Tool for experimental studies. RESULTS: Of 5,702 potentially relevant studies, we included 44 observational and 8 experimental studies. There was marked heterogeneity in the metrics used to define capacity strain, hospital settings, and overall study quality. Mortality increased during times of capacity strain in 18 of 30 studies and in 9 of 12 studies in intensive care unit settings. No experimental studies were randomized, and none demonstrated an improvement in health outcomes after implementing the intervention. The pediatric literature is very limited; only six observational studies included children. There was insufficient study homogeneity to perform meta-analyses. DISCUSSION: In highly developed countries, hospital capacity strain is associated with increased mortality and worsened health outcomes. Evidence-based solutions to improve outcomes during times of capacity strain are needed.

Perspectives and Uses of the Electronic Health Record Among US Pediatricians: A National Survey.

Little is known about how existing electronic health records (EHRs) influence the practice of pediatric medicine. A total of 808 pediatricians participated in a survey about workflows using the EHR. The EHR was the most commonly used source of initial patient information. Seventy-two percent reported requiring between 2 and 10 minutes to complete an initial review of the EHR. Several moderately severe information barriers were reported regarding the display of information in the EHR. Pediatricians acquire information about new patients from EHRs more often than any other source. EHRs play a critical role in pediatric care but require improved design and efficiency.

Care of the child with Ebola virus disease.

OBJECTIVES: To provide clinicians with practical considerations for care of children with Ebola virus disease in resource-rich settings. DATA SOURCES: Review of the published medical literature, World Health Organization and government documents, and expert opinion. DATA SYNTHESIS: There are limited data regarding Ebola virus disease in children; however, reported case-fatality proportions in children are high. Ebola virus may affect immune regulation and endothelial function differently in children than adults. Considerations for care of children with Ebola virus disease are presented. CONCLUSIONS: Ebola virus disease is a severe multisystem disease with high mortality in children and adults. Hospitals and clinicians must prepare to provide care for patients with Ebola virus disease before such patients present for care, with particular attention to rigorous infection control to limit secondary cases. Although there is no proven specific treatment for Ebola virus disease, meticulous supportive care offers patients the best chance of survival.

Variability in Electronic Health Record Usage and Perceptions among Specialty vs. Primary Care Physicians.

Despite federal incentives for adoption of electronic health records (EHRs), surveys have shown that EHR use is less common among specialty physicians than generalists. Concerns have been raised that current-generation EHR systems are inadequate to meet the unique information gathering needs of specialists. This study sought to identify whether information gathering needs and EHR usage patterns are different between specialists and generalists, and if so, to characterize their precise nature. We found that specialists and generalists have significantly different perceptions of which elements of the EHR are most important and how well these systems are suited to displaying clinical information. Resolution of these disparities could have implications for clinical productivity and efficiency, patient and physician satisfaction, and the ability of clinical practices to achieve Meaningful Use incentives.

Risk factors for mechanical ventilation in U.S. children hospitalized with seasonal influenza and 2009 pandemic influenza A*.

OBJECTIVE: We tested the hypothesis that the use of mechanical ventilator support in children hospitalized with influenza during the 2009 H1N1 influenza A (H1N1) pandemic was higher than would be expected in children hospitalized for seasonal influenza after adjusting for patient risk. DESIGN: Retrospective cohort study. SETTING: Forty-three U.S. pediatric hospitals. PATIENTS: Children <18 yrs old with a discharge diagnosis of influenza admitted July 2006 through March 2009 (seasonal influenza) and June through December 2009 (2009 pandemic influenza A). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We included 10,173 children hospitalized with seasonal influenza and 9837 with presumed 2009 pandemic influenza A. The 2009 pandemic influenza A cohort was older (median 5.0 vs. 1.9 yrs), more likely to have asthma (30% vs. 18%), and less likely to receive mechanical ventilation (7.1% [n = 701] vs. 9.2% [n = 940]). Using logistic regression, we created a multivariable model of risk factors associated with endotracheal mechanical ventilator support in the seasonal influenza cohort and used this model to predict the number of expected mechanical ventilation cases in children with presumed 2009 pandemic influenza A. Adjusted for underlying health conditions, race, age, and a co-diagnosis of bacterial pneumonia, the observed/expected rate of mechanical ventilation in the presumed 2009 pandemic influenza A cohort was 0.74 (95% confidence interval 0.68-0.79). Early hospital treatment with influenza antiviral medications was associated with decreased initiation of mechanical ventilation on hospital day ≥ 3 in the seasonal influenza (odds ratio 0.66; 95% confidence interval 0.45-0.97) and 2009 pandemic influenza A (odds ratio 0.23; 95% confidence interval 0.16-0.34) periods; influenza antiviral use in the 2009 pandemic influenza A period was much higher (70% vs. 20%; p < .001). CONCLUSIONS: Although the number of children with a hospital discharge diagnosis of influenza almost tripled during the 2009 pandemic influenza A period, the risk-adjusted proportion of children receiving mechanical ventilation was lower than we would have predicted in a seasonal influenza cohort. Early hospital use of influenza antiviral medications was associated with a decrease in late-onset mechanical ventilation.