Evaluation of methods used to verify nasogastric feeding tube placement in hospitalized infants and children - A follow-up study.

BACKGROUND: Nasogastric (NG) feeding tubes are used to deliver nutrition, hydration, and medications to hospitalized infants and children but the ongoing use of non-evidence-based practice (EBP) methods to confirm NG tube (NGT) placement has been associated with adverse patient events. METHODS: A study was undertaken to ascertain if practice changes have occurred since findings from a previous study were published by the New Opportunities for Verification of Enteral tube Location (NOVEL) project. The NOVEL project was an initiative of the American Society of Parenteral and Enteral Nutrition (ASPEN). A survey was distributed to member organizations participating in the NOVEL project. Respondents were also asked if and when a change in practice occurred in the policy for NGT placement verification, if there was variation within the institutional units and if there were barriers to practice change. FINDINGS: Respondents were primarily nurses (205/245) from 166 institutions that provided care to combined adult/pediatric/neonatal (122/166) patients. Respondents indicated a radiograph (64%) or pH measurement (24%) were best practice but in actual practice 42% use pH measurement and 23% use a radiograph to verify NGT placement. There was variability within institutions, with the Neonatal Intensive Care Unit (NICU) most often using aspiration and direct eye visualization to verify placement and the other units within the institutions using EBP method(s). DISCUSSION: Comparing these results to previous work by the NOVEL project shows an increase toward the use of EBP method(s) to verify NGT placement verification. APPLICATION TO PRACTICE: This study demonstrates variation within units at the same facility using methods unsupported by the literature, demonstrating that many centers still rely on non-EBP methods of NG placement confirmation, despite cautions issued by many major healthcare organizations.

The Child Health PSO at 10 Years: An Emerging Learning Network.

INTRODUCTION: The 2005 Patient Safety and Quality Improvement Act, actualized as a Learning Network (LN), has enabled the Child Health Patient Safety Organization (PSO) to play a vital and novel role in improving the quality and safety of care. This article describes the Child Health PSO and proposes PSOs as a new construct for LNs. METHODS: A PSOs ability to affect patient care depends on member organizations' integration of PSO output into their individual Learning Healthcare Systems. Therefore, the Child Health PSO developed tenets of an LN to improve member engagement in PSO outputs. RESULTS: All Child Health PSO members participate in case-based learning, requiring ongoing and robust participation by all members. The engagement has been strong, with 86% of children's hospitals achieving a case learning activity metric and 60% of children's hospitals submitting cases. From this LNs perspective, 53% of children's hospitals are considered highly engaged. CONCLUSIONS: In the last 10 years, the Child Health PSO has evolved as a viable LN and, to sustain this, has set a target of 100% of participating children's hospitals being highly engaged. The previously inconceivable notion of sharing information to improve patient safety among hospitals is now an expected result of the formation of trusting relationships under a federally certified PSO. According to participants, collaboration is an essential element that empowers individual children's hospitals to eliminate preventable harm.

Factors Related to Serious Safety Events in a Children's Hospital Patient Safety Collaborative.

BACKGROUND AND OBJECTIVES: Serious safety events (SSEs) occur infrequently at individual hospitals, making it difficult to establish trends to improve patient care. Patient safety organizations, such as the Child Health Patient Safety Organization (CHILDPSO), can identify trends and support learning across children's hospitals. We aim to describe longitudinal trends in SSE rates among CHILDPSO member hospitals and describe their sources of harm. METHODS: SSEs from 44 children's hospitals were assigned severity and reported to CHILDPSO from January 1, 2015, to December 31, 2018. SSEs were classified into groups and subgroups based on analysis. Events were then tagged with up to 3 contributing factors. Subgroups with <5 events were excluded. RESULTS: There were 22.5 million adjusted patient days included. The 12-month rolling average SSE rate per 10 000 adjusted patient days decreased from 0.71 to 0.41 (P < .001). There were 830 SSEs reported to CHILDPSO. The median hospital volume of SSEs was 12 events (interquartile range: 6-23), or ∼3 SSEs per year. Of the 830 events, 21.0% were high severity (SSE 1-3) and approximately two-thirds (67.0%, n = 610) were patient care management events, including subgroups of missed, delayed, or wrong diagnosis or treatment; medication errors; and suboptimal care coordination. The most common contributing factor was lack of situational awareness (17.9%, n = 382), which contributed to 1 in 5 (20%) high-severity SSEs. CONCLUSIONS: Hospitals sharing SSE data through CHILDPSO have seen a decrease in SSEs. Patient care management was the most frequently seen. Future work should focus on investigation of contributing factors and risk mitigation strategies.

Introduction, Transmission Dynamics, and Fate of Early Severe Acute Respiratory Syndrome Coronavirus 2 Lineages in Santa Clara County, California.

We combined viral genome sequencing with contact tracing to investigate introduction and evolution of severe acute respiratory syndrome coronavirus 2 lineages in Santa Clara County, California, from 27 January to 21 March 2020. From 558 persons with coronavirus disease 2019, 101 genomes from 143 available clinical samples comprised 17 lineages, including SCC1 (n = 41), WA1 (n = 9; including the first 2 reported deaths in the United States, with postmortem diagnosis), D614G (n = 4), ancestral Wuhan Hu-1 (n = 21), and 13 others (n = 26). Public health intervention may have curtailed the persistence of lineages that appeared transiently during February and March. By August, only D614G lineages introduced after 21 March were circulating in Santa Clara County.

Acidity of Enteral Feeding Tube Aspirate in Neonates: Do pH Values Meet the Cutoff for Predicting Gastric Placement?

BACKGROUND: Enteral feeding tubes (EFTs) are commonly used in neonatal practice, but complications from tube misplacement remain a concern. Measuring the pH of EFT aspirate is a recommended method to evaluate EFT placement. A pH value of ≤5.5 is considered predictive of gastric placement. Using this method in infants has been questioned. It is unclear whether infants can produce adequate gastric acid to achieve a pH 5 or less and whether feedings and medications influence pH. PURPOSE: To report EFT aspirate pH values in infants and to evaluate factors potentially influencing pH values. METHODS: A retrospective descriptive study was conducted with 1024 infants with 6979 pH values. Demographic and clinical data were collected including type of EFT, pH of gastric aspirate, feeding method, time of last feeding, and administration of acid suppression medications. The frequency of measured pH values of 5 or less was calculated for each covariate. FINDINGS/RESULTS: The majority (97.51%) of pH values were 5 or less. Orogastric tubes, continuous feeding, a 4-hour or more feeding interval, exposure to medications (proton pump inhibitor, histamine-2 receptor antagonist, or multiple medications) were associated with an increased likelihood of pH values of more than 5. However, with each study variable the majority of pH values were 5 or less. IMPLICATIONS FOR PRACTICE: These findings suggest EFT pH, a recommended method to evaluate the likelihood of gastric placement, can be successfully used in the neonatal population. IMPLICATIONS FOR RESEARCH: Future research should prospectively evaluate EFT pH in infants when compared with clinically indicated radiographs. Other factors that might influence pH should be explored including severity of illness, feeding type, and other medications.

Use of Temporary Enteral Access Devices in Hospitalized Neonatal and Pediatric Patients in the United States.

BACKGROUND: Temporary enteral access devices (EADs), such as nasogastric (NG), orogastric (OG), and postpyloric (PP), are used in pediatric and neonatal patients to administer nutrition, fluids, and medications. While the use of these temporary EADs is common in pediatric care, it is not known how often these devices are used, what inpatient locations have the highest usage, what size tube is used for a given weight or age of patient, and how placement is verified per hospital policy. MATERIALS AND METHODS: This was a multicenter 1-day prevalence study. Participating hospitals counted the number of NG, OG, and PP tubes present in their pediatric and neonatal inpatient population. Additional data collected included age, weight and location of the patient, type of hospital, census for that day, and the method(s) used to verify initial tube placement. RESULTS: Of the 63 participating hospitals, there was an overall prevalence of 1991 temporary EADs in a total pediatric and neonatal inpatient census of 8333 children (24% prevalence). There were 1316 NG (66%), 414 were OG (21%), and 261 PP (17%) EADs. The neonatal intensive care unit (NICU) had the highest prevalence (61%), followed by a medical/surgical unit (21%) and pediatric intensive care unit (18%). Verification of EAD placement was reported to be aspiration from the tube (n = 21), auscultation (n = 18), measurement (n = 8), pH (n = 10), and X-ray (n = 6). CONCLUSION: The use of temporary EADs is common in pediatric care. There is wide variation in how placement of these tubes is verified.

Nasogastric tube placement and verification in children: review of the current literature.

Placement of a nasogastric enteral access device (NG-EAD), often referred to as a nasogastric tube, is a common practice and largely in the domain of nursing care. Most often an NG-EAD is placed at the bedside without radiographic assistance. Correct initial placement and ongoing location verification are the primary challenges surrounding NG-EAD use and have implications for patient safety. Although considered an innocuous procedure, placement of an NG-EAD carries risk of serious and potentially lethal complications. Despite acknowledgment that an abdominal radiograph is the gold standard, other methods of verifying placement location are widely used and have success rates from 80% to 85%. The long-standing challenges surrounding bedside placement of NG-EADs and a practice alert issued by the Child Health Patient Safety Organization on this issue were the stimuli for the conception of The New Opportunities for Verification of Enteral Tube Location Project sponsored by the American Society for Parenteral and Enteral Nutrition. Its mission is to identify and promote best practices with the potential of technology development that will enable accurate determination of NG-EAD placement for both the inpatient and outpatient pediatric populations. This article presents the challenges of bedside NG-EAD placement and ongoing location verification in children through an overview of the current state of the science. It is important for all healthcare professionals to be knowledgeable about the current literature, to be vigilant for possible complications, and to avoid complacency with NG-EAD placement and ongoing verification of tube location.

Nasogastric tube placement and verification in children: review of the current literature.

Placement of a nasogastric enteral access device (NG-EAD), often referred to as a nasogastric tube, is common practice and largely in the domain of nursing care. Most often an NG-EAD is placed at the bedside without radiographic assistance. Correct initial placement and ongoing location verification are the primary challenges surrounding NG-EAD use and have implications for patient safety. Although considered an innocuous procedure, placement of an NG-EAD carries risk of serious and potentially lethal complications. Despite acknowledgment that an abdominal radiograph is the gold standard, other methods of verifying placement location are widely used and have success rates from 80% to 85%. The long-standing challenges surrounding bedside placement of NG-EADs and a practice alert issued by the Child Health Patient Safety Organization on this issue were the stimuli for the conception of The New Opportunities for Verification of Enteral Tube Location Project sponsored by the American Society for Parenteral and Enteral Nutrition. Its mission is to identify and promote best practices with the potential of technology development that will enable accurate determination of NG-EAD placement for both the inpatient and outpatient pediatric populations. This article presents the challenges of bedside NG-EAD placement and ongoing location verification in children through an overview of the current state of the science. It is important for all health care professionals to be knowledgeable about the current literature, to be vigilant for possible complications, and to avoid complacency with NG-EAD placement and ongoing verification of tube location.

A call to action: the development of enteral access safety teams.

Safety concerns regarding the verification of nasogastric feeding tube placement prompted the American Society for Parenteral and Enteral Nutrition to call for an interdisciplinary, interorganizational group to work on best practices and new technologies to address this issue in pediatric patients. This commentary calls for the development of specialized teams within hospitals to improve the quality of care provided to children and infants who require nasogastric feeding tubes. It is expands on the information presented in an article in the issue by Irving et al regarding the current status of nasogastric tube placement and verification methods.

Accelerated aging of selective brain structures in human immunodeficiency virus infection: a controlled, longitudinal magnetic resonance imaging study.

Advances in treatment have transformed human immunodeficiency virus (HIV) infection from an inexorable march to severe morbidity and premature death to a manageable chronic condition, often marked by good health. Thus, infected individuals are living long enough that there is a potential for interaction with normal senescence effects on various organ systems, including the brain. To examine this interaction, the brains of 51 individuals with HIV infection and 65 uninfected controls were studied using 351 magnetic resonance imaging and a battery of neuropsychological tests collected 2 or more times over follow-up periods ranging from 6 months to 8 years. Brain tissue regions of interest showed expected age-related decrease in volume; cerebrospinal fluid-filled spaces showed increase in volume for both groups. Although HIV-infected individuals were in good general health, and free of clinically-detectable dementia, several brain regions supporting higher-order cognition and integration of functions showed acceleration of the normal aging trajectory, including neocortex, which extended from the frontal and temporal poles to the parietal lobe, and the thalamus. Beyond an anticipated increase in lateral ventricle and Sylvian fissure volumes and decrease in tissue volumes (specifically, the frontal and sensorimotor neocortices, thalamus, and hippocampus) with longer duration of illness, most regions also showed accelerated disease progression. This accelerated loss of cortical tissue may represent a risk factor for premature cognitive and motor compromise if not dementia. On a more promising note, HIV-infected patients with increasing CD4 counts exhibited slower expansion of Sylvian fissure volume and slower declines of frontal and temporoparietal cortices, insula, and hippocampus tissue volumes. Thus, attenuated shrinkage of these brain regions, likely with adequate pharmacologic treatment and control of further infection, has the potential of abating decline in associated higher-order functions, notably, explicit memory, executive functions, self-regulation, and visuospatial abilities.

Engaging patients and families in system-level improvement: a safety imperative.

Health care organizations have focused considerable effort and resources on improving patient safety and health care quality. Yet, despite these efforts, patients continue to experience harm events within our institutions. Family engagement is a powerful and often untapped resource to improve the quality and safety of organizations. While the value patients and families bring as partners in improving the safety and quality of health care is implicitly recognized, the adoption of structures to actively involve health care consumers has been slow, particularly in organizational or overall system work. Patients and families can stimulate and drive improved health care services through their involvement at the clinical/point of care, policy/design, and governance levels of the organization. For successful implementation, organization leaders must establish family engagement as a system-level priority. Roles to support the development of a family engagement program, methods to evaluate the level of family engagement, and strategies to enhance and sustain family engagement are described. Although there is limited evidence-based knowledge related to the best practices for family engagement, opportunities exist to drive the family engagement agenda at a regional and national level through participation in networks such as the Centers for Medicare & Medicaid Services Partnership for Patients campaign Hospital Engagement Networks.

Regional brain structural dysmorphology in human immunodeficiency virus infection: effects of acquired immune deficiency syndrome, alcoholism, and age.

BACKGROUND: Human immunodeficiency virus (HIV) infection and alcoholism each carries liability for disruption of brain structure and function integrity. Despite considerable prevalence of HIV-alcoholism comorbidity, few studies examined the potentially heightened burden of disease comorbidity. METHODS: Participants were 342 men and women: 110 alcoholics, 59 with HIV infection, 65 with HIV infection and alcoholism, and 108 healthy control subjects. This design enabled examination of independent and combined effects of HIV infection and alcoholism along with other factors (acquired immune deficiency syndrome [AIDS]-defining events, hepatitis C infection, age) on regional brain volumes derived from T1-weighted magnetic resonance images. RESULTS: Brain volumes, expressed as Z scores corrected for intracranial volume and age, were measured in 20 tissue and 5 ventricular and sulcal regions. The most profound and consistent volume deficits occurred with alcohol use disorders, notable in the cortical mantle, insular and anterior cingulate cortices, thalamus, corpus callosum, and frontal sulci. The HIV-only group had smaller thalamic and larger frontal sulcal volumes than control subjects. HIV disease-related factors associated with greater volume abnormalities included CD4 cell count nadir, clinical staging, history of AIDS-defining events, infection age, and current age. Longer sobriety and less lifetime alcohol consumption were predictive of attenuated brain volume abnormalities in both alcohol groups. CONCLUSIONS: Having HIV infection with alcoholism and AIDS had an especially poor outcome on brain structures. That longer periods of sobriety and less lifetime alcohol consumption were predictive of attenuated brain volume abnormalities encourages the inclusion of alcohol recovery efforts in HIV/AIDS therapeutic settings.

Developing and testing a clinical information system evaluation tool: prioritizing modifications through end-user input.

OBJECTIVE: The objectives were to develop and validate the Information System Evaluation Tool (ISET), use feedback to modify the institution's clinical information system (CIS), and determine the modifications' success. BACKGROUND: The ability of a CIS to increase patient safety and care quality is dependent on its systems and processes. A survey was needed to provide the specificity necessary to make meaningful system improvements. METHODS: The ISET was pilot tested and revised before being administered before implementation of the CIS. It was administered at 2 times after implementation. The ISET was revised after analysis of the results, and comparisons were made between the times. RESULTS: The ISET is a valid and reliable instrument. Perceptions of the CIS initially decreased, but had significantly improved by 16 months after implementation. CONCLUSIONS: End-users must be convinced that the CIS supports their practice and improves care for adoption to be successful. The ISET measures these perceptions and highlights areas for improvement.

Pontocerebellar contribution to postural instability and psychomotor slowing in HIV infection without dementia.

Postural instability occurs in HIV infection, but quantitative balance tests in conjunction with neuroimaging are lacking. We examined whether infratentorial brain tissue volume would be deficient in nondemented HIV-infected individuals and whether selective tissue deficits would be related to postural stability and psychomotor speed performance. The 123 participants included 28 men and 12 women with HIV infection without dementia or alcohol use disorders, and 40 men and 43 women without medical or psychiatric conditions. Participants completed quantitative balance testing, Digit Symbol test, and a test of finger movement speed and dexterity. An infratentorial brain region, supratentorial ventricular system, and corpus callosum were quantified with MRI-derived atlas-based parcellation, and together with archival DTI-derived fiber tracking of pontocerebellar and internal and external capsule fiber systems, brain measures were correlated with test performance. The tissue ratio of the infratentorium was ~3% smaller in the HIV than control group. The HIV group exhibited performance deficits in balancing on one foot, walking toe-to-heel, Digit Symbol substitution task, and time to complete all Digit Symbol grid boxes. Total infratentorial tissue ratio was a significant predictor of balance and Digit Symbol scores. Balance scores did not correlate significantly with ventricular volumes, callosal size, or internal or external capsule fiber integrity but did so with indices of pontocerebellar tract integrity. HIV-infected individuals specifically recruited to be without complications from alcohol use disorders had pontocerebellar tissue volume deficits with functional ramifications. Postural stability and psychomotor speed were impaired and attributable, at least in part, to compromised infratentorial brain systems.

Abacavir and tenofovir disoproxil fumarate co-administration results in a nonadditive antiviral effect in HIV-1-infected patients.

OBJECTIVES: To evaluate a potential pharmacodynamic/pharmacokinetic interaction between abacavir (ABC) and tenofovir disoproxil fumarate (TDF). DESIGN AND METHODS: This randomized trial compared 7 days of ABC or TDF monotherapy, separated by a 35-day washout, with 7 days of ABC + TDF dual-therapy in treatment-naive, HIV-1-infected patients. During each 7-day course, the slope of the phase I viral decay was estimated and steady-state intracellular concentrations of carbovir triphosphate (CBV-TP), deoxyguanosine triphosphate (dGTP), tenofovir diphosphate (TFV-DP) and deoxyadenosine triphosphate (dATP) were determined. RESULTS: Twenty-one participants were randomized to initial monotherapy with ABC (n = 11) or TDF (n = 10). The addition of TDF did not increase the slope of viral decay compared to ABC alone (-0.15 log10 per day vs. -0.16 log10 per day, respectively). No decrease in CBV-TP or TFV-DP between monotherapy and dual-therapy was observed. However, intracellular dATP concentrations increased between monotherapy and dual-therapy [median dATP (fmol/10 cells) 3293 vs. 4638; P = 0.08], although this difference was significant only among patients randomized to TDF [median dATP (fmol/10 cells) 3238 vs. 4534; P = 0.047]. A lower TFV-DP-to-dATP ratio was associated with reduced viral decay during dual-therapy (rho = -0.529; P = 0.045). CONCLUSION: In this study, the viral decay during ABC and TDF dual-therapy was similar to that during ABC therapy alone, suggesting a nonadditive antiviral effect. This negative pharmacodynamic interaction was not explained by changes in CBV-TP or TFV-DP concentrations. Rather, modest increases in endogenous dATP pools were associated with reduced antiviral potency of TDF during co-administration with ABC.

Frontostriatal fiber bundle compromise in HIV infection without dementia.

BACKGROUND: Quantitative fiber tracking derived from diffusion tensor imaging (DTI) was used to determine whether white matter association, projection, or commissural tracts are affected in nondemented individuals with HIV infection and to identify the regional distribution of sparing and impairment of fiber systems. METHODS: DTI measured fractional anisotropy and diffusivity, quantified separately for longitudinal (lambdaL) diffusivity (index of axonal injury) and transverse (lambdaT) diffusivity (index of myelin injury), in 11 association and projection white matter tracts and six commissural tracts in 29 men and 13 women with HIV infection and 88 healthy, age-matched controls (42 men and 46 women). RESULTS: The total group of HIV-infected individuals had higher diffusivity (principally longitudinal) than controls in the posterior sectors of the corpus callosum, internal and external capsules, and superior cingulate bundles. High longitudinal diffusivity, indicative of axonal compromise, was especially prominent in posterior callosal sectors, fornix, and superior cingulate bundle in HIV with AIDS. Unmedicated patients had notably high transverse diffusivity, indicative of myelin compromise, in the occipital forceps, inferior cingulate bundle, and superior longitudinal fasciculus. Pontocerebellar projection fibers were resistant to HIV effects as were commissural fibers coursing through premotor and sensorimotor callosal sectors. CONCLUSION: This quantitative survey of brain fiber tract integrity indicates that even nondemented HIV patients can have neuroradiological evidence for damage to association and commissural tracts. These abnormalities were vulnerable to exacerbation with AIDS and possibly mitigated by HAART.