Levofloxacin prophylaxis in pediatric oncology and hematopoietic stem cell transplantation: a literature review.

Bloodstream infections (BSI) are one of the leading causes of morbidity and mortality in children and young adults receiving chemotherapy for malignancy or undergoing hematopoietic stem cell transplantation (HSCT). Antibiotic prophylaxis is commonly used to decrease the risk of BSI; however, antibiotics carry an inherent risk of complications. The aim of this manuscript is to review levofloxacin prophylaxis in pediatric oncology patients and HSCT recipients. We reviewed published literature on levofloxacin prophylaxis to prevent BSI in pediatric oncology patients and HSCT recipients. Nine manuscripts were identified. The use of levofloxacin is indicated in neutropenic children and young adults receiving intensive chemotherapy for leukemia or undergoing HSCT. These results support the efficacy of levofloxacin in pediatric patients with leukemia receiving intensive chemotherapy and should be considered in pediatric patients undergoing HSCT prior to engraftment.

Racial and ethnic disparities in common inpatient safety outcomes in a children's hospital cohort.

BACKGROUND: Emerging evidence has shown racial and ethnic disparities in rates of harm for hospitalised children. Previous work has also demonstrated how highly heterogeneous approaches to collection of race and ethnicity data pose challenges to population-level analyses. This work aims to both create an approach to aggregating safety data from multiple hospitals by race and ethnicity and apply the approach to the examination of potential disparities in high-frequency harm conditions. METHODS: In this cross-sectional, multicentre study, a cohort of hospitals from the Solutions for Patient Safety network with varying race and ethnicity data collection systems submitted validated central line-associated bloodstream infection (CLABSI) and unplanned extubation (UE) data stratified by patient race and ethnicity categories. Data were submitted using a crosswalk created by the study team that reconciled varying approaches to race and ethnicity data collection by participating hospitals. Harm rates for race and ethnicity categories were compared with reference values reflective of the cohort and broader children's hospital population. RESULTS: Racial and ethnic disparities were identified in both harm types. Multiracial Hispanic, Combined Hispanic and Native Hawaiian or other Pacific Islander patients had CLABSI rates of 2.6-3.6 SD above reference values. For Black or African American patients, UE rates were 3.2-4.4 SD higher. Rates of both events in White patients were significantly lower than reference values. CONCLUSIONS: The combination of harm data across hospitals with varying race and ethnicity collection systems was accomplished through iterative development of a race and ethnicity category framework. We identified racial and ethnic disparities in CLABSI and UE that can be addressed in future improvement work by identifying and modifying care delivery factors that contribute to safety disparities.

Pediatric Ventilator-Associated Events Before and After a Multicenter Quality Improvement Initiative.

Importance: Pediatric ventilator-associated events (PedVAEs, defined as a sustained worsening in oxygenation after a baseline period of stability or improvement) are useful for surveillance of complications from mechanical ventilation. It is unclear whether interventions to mitigate known risk factors can reduce PedVAE rates. Objective: To assess whether adherence to 1 or more test factors in a quality improvement bundle was associated with a reduction in PedVAE rates. Design, Setting, and Participants: This multicenter quality improvement study obtained data from 2017 to 2020 for patients who were mechanically ventilated and cared for in neonatal, pediatric, and cardiac intensive care units (ICUs). These ICUs were located in 95 hospitals participating in the Children's Hospitals' Solutions for Patient Safety (SPS) network in North America. Data analyses were performed between September 2021 and April 2023. Intervention: A quality improvement bundle consisted of 3 test factors: multidisciplinary apparent cause analysis, daily discussion of extubation readiness, and daily discussion of fluid balance goals. This bundle was distributed to a subgroup of hospitals that volunteered to participate in a collaborative PedVAE prevention initiative under the SPS network guidance in July 2018. Main Outcomes and Measures: Each SPS network hospital submitted monthly PedVAE rates from January 1, 2017, to May 31, 2020, and test factor data were submitted from July 1, 2018, to May 31, 2020. Analyses focused on hospitals that reliably submitted PedVAE rate data, defined as outcomes data submission through May 31, 2020, for at least 80% of the baseline and postbaseline periods. Results: Of the 95 hospitals in the SPS network that reported PedVAE data, 21 were grouped in the Pioneer cohort and 74 in the non-Pioneer cohort. Only 12 hospitals (57%) from the 21 Pioneer hospitals and 33 (45%) from the 74 non-Pioneer hospitals were considered to be reliable reporters of outcome data. Among the 12 hospitals, the PedVAE rate decreased from 1.9 to 1.4 events per 1000 ventilator days (absolute rate difference, -0.6; 95% CI, -0.5 to -0.7; P < .001). No significant change in the PedVAE rate was seen among the 33 hospitals that reliably submitted PedVAE rates but did not implement the bundle. Of the 12 hospitals, 3 that reliably performed daily discussion of extubation readiness had a decrease in PedVAE rate from 2.6 to 1.2 events per 1000 ventilator days (absolute rate difference, -1.4; 95% CI, -1.0 to -1.7; P < .001), whereas the other 9 hospitals that did not implement this discussion did not have a decrease. Conclusions and Relevance: This study found that a multicenter quality improvement intervention targeting PedVAE risk factors was associated with a substantial reduction in the rate of PedVAEs in hospital ICUs. The findings suggest that ICU teams seeking to reduce PedVAEs incorporate daily discussion of extubation readiness during morning rounds.

Compliance With Central Line Maintenance Bundle and Infection Rates.

BACKGROUND: Reliable bundle performance is the mainstay of central line-associated bloodstream infections (CLABSI) prevention despite an unclear relationship between bundle reliability and outcomes. Our primary objective was to evaluate the correlation between reported bundle compliance and CLABSI rate in the Solutions for Patient Safety network. The secondary objective was to identify which hospital and process factors impact this correlation. METHODS: We examined data on bundle compliance and monthly CLABSI rates from January 11 to December 21 in 159 hospitals. The correlation (adjusting for temporal trend) between CLABSI rates and bundle compliance was done at the network level. Negative binomial regression was done to detect the impact of hospital type, central line audit rate, and adoption of a comprehensive safety culture program on the association between bundle compliance and CLABSI rates. RESULTS: During the study, hospitals reported 27 196 CLABSI on 20 274 565 line days (1.34 CLABSI/1000 line days). Out of 2 460 133 observed bundle opportunities, 2 085 700 (84%) were compliant. There was a negative correlation between the monthly bundle reliability and monthly CLABSI rate (-0.35, P <.001). After adjusting for the temporal trend, the partial correlation was -0.25 (P = .004). On negative binomial regression, significant positive interaction was only noted for the hospital type, with Hospital Within Hospital (but not freestanding children's hospitals) revealing a significant association between compliance ≥95% and lower CLABSI rates. CONCLUSIONS: Adherence to best practice guidelines is associated with a reduction in CLABSI rate. Hospital-level factors (hospitals within hospitals vs freestanding), but not process-related (central line audit rate and safety culture training), impact this association.

Association Between Hospital-Acquired Harm Outcomes and Membership in a National Patient Safety Collaborative.

Importance: Hospital engagement networks supported by the US Centers for Medicare & Medicaid Services Partnership for Patients program have reported significant reductions in hospital-acquired harm, but methodological limitations and lack of peer review have led to persistent questions about the effectiveness of this approach. Objective: To evaluate associations between membership in Children's Hospitals' Solutions for Patient Safety (SPS), a federally funded hospital engagement network, and hospital-acquired harm using standardized definitions and secular trend adjustment. Design, Setting, and Participants: This prospective hospital cohort study included 99 children's hospitals. Using interrupted time series analyses with staggered intervention introduction, immediate and postimplementation changes in hospital-acquired harm rates were analyzed, with adjustment for preexisting secular trends. Outcomes were further evaluated by early-adopting (n = 73) and late-adopting (n = 26) cohorts. Exposures: Hospitals implemented harm prevention bundles, reported outcomes and bundle compliance using standard definitions to the network monthly, participated in learning events, and implemented a broad safety culture program. Hospitals received regular reports on their comparative performance. Main Outcomes and Measures: Outcomes for 8 hospital-acquired conditions were evaluated over 1 year before and 3 years after intervention. Results: In total, 99 hospitals met the inclusion criteria and were included in the analysis. A total of 73 were considered part of the early-adopting cohort (joined between 2012-2013) and 26 were considered part of the late-adopting cohort (joined between 2014-2016). A total of 42 hospitals were freestanding children's hospitals, and 57 were children's hospitals within hospital or health systems. The implementation of SPS was associated with an improvement in hospital-acquired condition rates in 3 of the 8 conditions after accounting for secular trends. Membership in the SPS was associated with an immediate reduction in central catheter-associated bloodstream infections (coefficient = -0.152; 95% CI, -0.213 to -0.019) and falls of moderate or greater severity (coefficient = -0.331; 95% CI, -0.594 to -0.069). The implementation of the SPS was associated with a reduction in the monthly rate of adverse drug events (coefficient = -0.021; 95% CI, -0.034 to -0.008) in the post-SPS period. The study team observed larger decreases for the early-adopting cohort compared with the late-adopting cohort. Conclusions and Relevance: Through the application of rigorous methods (standard definitions and longitudinal time series analysis with adjustment for secular trends), this study provides a more thorough analysis of the association between the Partnership for Patients hospital engagement network model and reductions in hospital-acquired conditions. These findings strengthen previous claims of an association between this model and improvement. However, inconsistent observations across hospital-acquired conditions when adjusted for secular trends suggests that some caution regarding attributing all effects observed to this model is warranted.

Developing Evidence for New Patient Safety Bundles Through Multihospital Collaboration.

OBJECTIVE: Multihospital collaboration for safety improvements is increasingly common, but strategies for developing bundles when effective evidence-based practices are not well described are limited. The Children's Hospitals' Solutions for Patient Safety (SPS) Network sought to further reduce patient harm by developing improvement bundles when preliminary evidence was limited. METHODS: As part of the novel Pioneer process, cohorts of volunteer SPS hospitals collaborated to identify a harm reduction bundle for carefully selected hospital-acquired harm categories where evidence-based practices were limited. For each harm type, a leadership team selected interventions (factors) for testing and guided the work throughout the Pioneer process. Using fundamental quality improvement techniques and a planned experimentation design, each participating hospital submitted outcome and process compliance data for the factor implemented. Data from all hospitals implementing that factor were analyzed together using Shewhart charts, response plots, and analysis of covariance to identify whether reliable implementation of the factor influenced outcomes. Factors were categorized based on strength of evidence and other clinical or evidentiary support. Factors with strong support were included in a final bundle and disseminated to all SPS hospitals. RESULTS: The SPS began the bundle identification process for nine harm types and three have completed the process. The analytic approach resulted in four scenarios that along with clinical input guided the inclusion or rejection of the factor in the final bundle. CONCLUSIONS: In this multihospital collaborative, quality improvement methods and planned experimentation were effective at developing evidence-based harm reduction bundles in situations where limited data for interventions exist.

Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children.

Importance: Unplanned extubations (UEs) in children contribute to significant morbidity and mortality, with an arbitrary benchmark target of less than 1 UE per 100 ventilator days. However, there have been no multicenter initiatives to reduce these events. Objective: To determine if a multicenter quality improvement initiative targeting all intubated neonatal and pediatric patients is associated with a reduction in UEs and morbidity associated with UE events. Design, Setting, and Participants: This multicenter quality improvement initiative enrolled patients from pediatric, neonatal, and cardiac intensive care units (ICUs) in 43 participating children's hospitals from March 2016 to December 2018. All patients with an endotracheal tube requiring mechanical ventilation were included in the study. Interventions: Participating hospitals implemented a quality improvement bundle to reduce UEs, which included standardized anatomic reference points and securement methods, protocol for high-risk situations, and multidisciplinary apparent cause analyses. Main Outcomes and Measures: The main outcome measures for this study included bundle compliance with each factor tested and UE rates on the center level and on the cohort level. Results: Among the 43 children's hospitals, the quality improvement initiative was associated with an aggregate 24.1% reduction in UE events, from a baseline rate of 1.135 UEs per 100 ventilator days to 0.862 UEs per 100 ventilator days. Across ICU settings studied, the pediatric ICU and neonatal ICU demonstrated centerline shifts, with an absolute reduction in events of 20.6% (from a baseline rate of 0.729 UEs per 100 ventilator days to 0.579 UEs per 100 ventilator days) and 17.6% (from a baseline rate of 1.555 UEs per 100 ventilator days to 1.282 UEs per 100 ventilator days), respectively. Most UEs required reintubation within 1 hour (mean of 120 of 206 events per month [58.3%]), followed by UEs that did not require reintubation (mean of 78 of 206 events per month [37.9%]) and UEs that resulted in cardiovascular collapse (mean of 8 of 206 events per month [3.9%]). Cardiovascular collapse events represented the most significant consequence of UE studied, and the collaborative reduced these UE events by 36.6%, from a study baseline rate of 0.041 UEs per 100 ventilator days to 0.026 UEs per 100 ventilator days. Conclusions and Relevance: This multicenter quality improvement initiative was associated with a reduction in UEs across different pediatric populations in diverse settings. A significant reduction in event rate and rate of harm (cardiovascular collapse) was observed, which was sustained over the time course of the intervention. This quality improvement process and UE bundle may be considered standard of care for pediatric hospitals in the future.

Variability in Collection and Use of Race/Ethnicity and Language Data in 93 Pediatric Hospitals.

OBJECTIVE: To describe how pediatric hospitals across the USA and Canada collect race/ethnicity and language preference (REaL) data and how they stratify quality and safety metrics using such data. METHODS: Pediatric hospitals from the Solutions for Patient Safety network (125 US, 6 Canadian) were surveyed between January and March 2018 on collection and use of patient/family race/ethnicity data and patient/family language preference data. The study team created the survey using a formal process including pre-testing. Responses were analyzed using descriptive statistics. RESULTS: Ninety-three of 131 (71%) hospitals completed the survey (87/125 [70%] US, 6/6 [100%] Canadian). Patient race/ethnicity was collected by 95%, parent/guardian race/ethnicity was collected by 31%, and 5/6 Canadian hospitals collected neither. Minimum government race/ethnicity categories were used without modification/addition by 68% of US hospitals. Eleven hospitals (13%) offered a multiracial/multiethnic option. Most hospitals reported collecting language preferences of parent/guardian (81%) and/or patient (87%). A majority provided formal training on data collection for race/ethnicity (70%) and language preferences (70%); fewer had a written policy (41%, 51%). Few hospitals stratified hospital quality and safety measures by race/ethnicity (20% readmissions, 20% patient/family experience, 16% other) or language preference (21% readmissions, 21% patient/family experience, 8% other). CONCLUSIONS: The variability of REaL data collection practices among pediatric hospitals highlights the importance of examining the validity and reliability of such data, especially when combined from multiple hospitals. Nevertheless, while improvements in data accuracy and standardization are sought, efforts to identify and eliminate disparities should be developed concurrently using existing data.

We Will Not Compete on Safety: How Children's Hospitals Have Come Together to Hasten Harm Reduction.

BACKGROUND: Launched in 2012, the Children's Hospitals' Solutions for Patient Safety (SPS) Network is a collaborative of children's hospitals in the United States and Canada working together to eliminate patient and employee/staff harm across all children's hospitals. METHODS: The SPS Network, which has grown from 8 to 137 hospitals, has a foundation of leadership engagement, noncompetition, data-driven learning, attention to safety culture, family engagement, and transparency. The SPS Leadership Group, which consists of more than 150 leaders from participating hospitals, forms condition-specific teams to promote the reduction of hospital-acquired harm in a phased design that includes an ongoing focus on both process improvement and safety culture enhancements. Hospital leaders are engaged through monthly reports, executive webinars, in-person meetings, and biannual training opportunities for boards of trustees. SPS has developed extensive opportunities for learning collaboration, including in-person networkwide learning sessions, regional meetings, general and condition-specific webinars, communications, and a shared website. RESULTS: Over time, the portfolio has expanded as SPS has achieved harm reduction targets for some conditions and begun work to reduce harm in other, previously unaddressed areas. In 2017 SPS reported a 9%-71% reduction in eight harm conditions by an initial cohort of 33 hospitals. SPS estimates that more than 9,000 children have been spared harm since 2012, with $148.5 million in health care spending avoided. CONCLUSION: Participation in the SPS Network has been associated with improved safety in children's hospitals. Widespread participation in this or similar collaborations has the potential to dramatically decrease harm to patients, employees, and staff.

Children's Hospitals' Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm.

OBJECTIVES: To determine if an improvement collaborative of 33 children's hospitals focused on reliable best practice implementation and culture of safety improvements can reduce hospital-acquired conditions (HACs) and serious safety events (SSEs). METHODS: A 3-year prospective cohort study design with a 12-month historical control population was completed by the Children's Hospitals' Solutions for Patient Safety collaborative. Identification and dissemination of best practices related to 9 HACs and SSE reduction focused on key process and culture of safety improvements. Individual hospital improvement teams leveraged the resources of a large, structured children's hospital collaborative using electronic, virtual, and in-person interactions. RESULTS: Thirty-three children's hospitals from across the United States volunteered to be part of the Children's Hospitals' Solutions for Patient Safety collaborative. Thirty-two met all the data submission eligibility requirements for the HAC improvement objective of this study, and 21 participated in the high-reliability culture work aimed at reducing SSEs. Significant harm reduction occurred in 8 of 9 common HACs (range 9%-71%; P < .005 for all). The mean monthly SSE rate decreased 32% (from 0.77 to 0.52; P < .001). The 12-month rolling average SSE rate decreased 50% (from 0.82 to 0.41; P < .001). CONCLUSIONS: Participation in a structured collaborative dedicated to implementing HAC-related best-practice prevention bundles and culture of safety interventions designed to increase the use of high-reliability organization practices resulted in significant HAC and SSE reductions. Structured collaboration and rapid sharing of evidence-based practices and tools are effective approaches to decreasing hospital-acquired harm.

Ohio Children's Hospitals' Solutions for Patient Safety: A Framework for Pediatric Patient Safety Improvement.

OBJECTIVES: Building upon their previous collective success and a clinical imperative for rapid improvement, the eight tertiary pediatric referral centers in Ohio sought to dramatically decrease the most serious types of harm that occur to hospitalized children by collectively employing high reliability methods focused on safety culture. METHODS: With the support of the hospitals' executives, the Ohio collaborative obtained legal protection and built will by clearly identifying types and frequency of harm events that occur in each participating hospital and across the state. The improvement efforts were divided among task forces designed to incorporate the principles of high reliability organizations into the work of all employees, focusing primarily on the consistent application of error prevention behaviors. RESULTS: Between January 2010 and October 2012, the serious safety event rate among the participating hospitals decreased by 55%, equating to 70 fewer children per year who experienced this most severe type of event in the participating hospitals. Between January 2011 and October 2012, all events of serious harm were decreased by 40%, meaning 18 fewer children per month suffered serious harm. CONCLUSION: Rapid and significant improvement in pediatric patient safety is possible through collaboration of children's hospitals dedicated to the application of high reliability principles and the noncompetitive sharing of outcomes and best practices.

A statewide collaborative to reduce pediatric surgical site infections.

BACKGROUND: Surgical site infections (SSIs) are preventable events associated with significant morbidity and cost. Few interventions have been tested to reduce SSIs in children. METHODS: A quality improvement collaboration was established in Ohio composed of all referral children's hospitals. Collaborative leaders developed an SSI reduction bundle for selected cardiac, orthopedic, and neurologic operations. The bundle was composed of 3 elements: prohibition of razors for skin preparation, chlorhexidine-alcohol use for incisional site preparation, and correct timing of prophylactic antibiotic administration. The incidence of SSIs across the collaborative was compared before and after institution of the bundle. The association between 1 of the bundle elements, namely correct timing of antibiotic prophylaxis, and the proportion of centers achieving 0 SSIs per month was measured. RESULTS: Eight pediatric hospitals participated. The proportion of months in which 0 SSIs per center was recorded was 56.9% before introduction of the bundle, versus 81.8% during the intervention (P < .001). Correct timing of preoperative prophylactic antibiotics also significantly improved; 39.4% of centers recorded correct timing in every eligible surgical procedure per month ("perfect timing") before the intervention versus 78.7% after (P < .001). The achievement of 0 SSIs per center in a given month was associated with the achievement of perfect antibiotic timing for that month (P < .003). CONCLUSIONS: A statewide collaborative of children's hospitals was successful in reducing the occurrence of SSIs across Ohio.

The choking game: physician perspectives.

OBJECTIVE: The goal was to assess awareness of the choking game among physicians who care for adolescents and to explore their opinions regarding its inclusion in anticipatory guidance. METHODS: We surveyed 865 pediatricians and family practitioners. The survey was designed to assess physicians' awareness of the choking game and its warning signs, the suspected prevalence of patients' participation in the activity, and the willingness of physicians to include the choking game in adolescent anticipatory guidance. Information on the general use of anticipatory guidance also was collected. RESULTS: The survey was completed by 163 physicians (response rate: 21.8%). One-hundred eleven (68.1%) had heard of the choking game, 68 of them (61.3%) through sources in the popular media. General pediatricians were significantly more likely to report being aware of the choking game than were family practitioners or pediatric subspecialists (P = .004). Of physicians who were aware of the choking game, 75.7% identified >or=1 warning sign and 52.3% identified >or=3. Only 7.6% of physicians who were aware of the choking game reported that they cared for a patient they suspected was participating in the activity, and 2 (1.9%) reported that they include the choking game in anticipatory guidance for adolescents. However, 64.9% of all respondents agreed that the choking game should be included in anticipatory guidance. CONCLUSIONS: Close to one third of physicians surveyed were unaware of the choking game, a potentially life-threatening activity practiced by adolescents. Despite acknowledging that the choking game should be included in adolescent anticipatory guidance, few physicians reported actually discussing it. To provide better care for their adolescent patients, pediatricians and family practitioners should be knowledgeable about risky behaviors encountered by their patients, including the choking game, and provide timely guidance about its dangers.

Understanding confidentiality: perspectives of African American adolescents and their parents.

PURPOSE: To identify adolescents' and parents' understanding of confidentiality in the patient/doctor relationship. METHODS: In the teen clinic of an academic hospital, questionnaires were administered separately to 50 accompanying parents and 50 adolescents aged 13 to 17 years. The true/false questions were designed to identify both adolescents' and parents' perceptions of the general breadth and limitations of confidentiality and specifically related to selected high-risk behaviors. RESULTS: Most adolescents and parents understood confidentiality to mean that conversations, testing and treatments about certain aspects of health care could be kept private between a doctor and patient. However, most parents felt that confidentiality guidelines did not apply to patients under 18 years. In contrast to 36% of adolescents, 96% of parents believe that the doctor would discuss any conversation the doctor had with the patient that might be important to the parent in spite of adolescents' wish for them not to be told. Parent/adolescent dyads agreed regarding the general value of a confidential adolescent/doctor relationship and the application of confidentiality to certain topics but disagreed with respect to others. CONCLUSIONS: The adolescents and parents in this study have a good understanding of the meaning of confidentiality but are less clear on its application to the adolescent patient/doctor relationship. Nearly all adolescents and their parents appreciate the circumstances under which confidentiality will be breached. The protections confidentiality offers adolescents are understood less well by both parties, but parents seem to have a greater degree of misunderstanding. Parents believe that the doctor will inform them about many of their adolescents' high-risk behaviors. These false impressions may lead to assumptions, miscommunication, and conflict in the adolescent patient/doctor/parent triad.