Clinical decision support to enhance venous thromboembolism pharmacoprophylaxis prescribing for pediatric inpatients with COVID-19.

OBJECTIVE: To design and evaluate a clinical decision support (CDS) module to improve guideline concordant venous thromboembolism (VTE) pharmacoprophylaxis prescribing for pediatric inpatients with COVID-19. MATERIALS AND METHODS: The proportion of patients who met our institutional clinical practice guideline's (CPG) criteria for VTE prophylaxis was compared to those who triggered a CDS alert, indicating the patient needed VTE prophylaxis, and to those who were prescribed prophylaxis pre and post the launch of a new VTE CDS module to support VTE pharmacoprophylaxis prescribing. The sensitivity, specificity, positive predictive value (PPV), negative predictive value, F1-score and accuracy of the tool were calculated for the pre- and post-intervention periods using the CPG recommendation as the gold standard. Accuracy was defined as the sum of the true positives and true negatives over the sum of the true positives, false positives, true negatives, and false negatives. Logistic regression was used to identify variables associated with correct thromboprophylaxis prescribing. RESULTS: A significant increase in the proportion of patients triggering a CDS alert occurred in the post-intervention period (44.3% vs. 6.9%, p < .001); however, no reciprocal increase in VTE prophylaxis prescribing was achieved (36.6% vs. 40.9%, p = .53). The updated CDS module had an improved sensitivity (55.0% vs. 13.3%), NPV (44.9% vs. 36.3%), F1-score (66.7% vs. 23.5%), and accuracy (62.5% vs. 42.0%), but an inferior specificity (78.6% vs. 100%) and PPV (84.6% vs. 100%). DISCUSSION: The updated CDS model had an improved accuracy and overall performance in correctly identifying patients requiring VTE prophylaxis. Despite an increase in correct patient identification by the CDS module, the proportion of patients receiving appropriate pharmacologic prophylaxis did not change. CONCLUSION: CDS tools to support correct VTE prophylaxis prescribing need ongoing refinement and validation to maximize clinical utility.

A Year of Inpatient Telehealth: Lessons From the COVID-19 Pandemic.

BACKGROUND: Relaxation of telehealth regulation enforcement during the coronavirus disease 2019 pandemic opened the door to massive expansion. Here we describe inpatient telehealth usage across a pediatric academic hospital during the first year of the pandemic. METHODS: We created hospital bed-specific inpatient telehealth accounts and monitored their use over a 1 year period using data from our video conferencing vendor. We matched data with our enterprise data warehouse based on session date and time to identify patients who participated in telehealth. We performed secondary analysis of all video conferences to identify additional multidisciplinary team and family meetings that did not leverage the bed-specific telehealth accounts. RESULTS: We hosted 6931 inpatient telehealth sessions associated with 1648 unique patients. Hospitalized patients participating in telehealth sessions were older and had markedly longer length of stay compared with those who did not use telehealth (median age 12 vs 8 years, P < .001; median length of stay 9.03 vs 2.03 days, P < .001). There were 2006 charges for telehealth sessions, half of which were from psychiatry providers. Secondary analysis revealed an additional 1132 sessions used for interdisciplinary team or family meetings. CONCLUSIONS: Clinicians used inpatient telehealth to support care of hospitalized pediatric patients during the coronavirus disease pandemic, particularly for mental health care and family meetings. These findings suggest ongoing opportunities for inpatient telehealth systems beyond the pandemic.

Improving guideline-concordant thromboprophylaxis prescribing for children admitted to hospital with COVID-19.

BACKGROUND: The incidence of venous thrombo-embolism (VTE) in hospitalized children has increased by 130%-200% over the last two decades. Given this increase, many centers utilize electronic clinical decision support (CDS) to prognosticate VTE risk and recommend prophylaxis. SARS-CoV-2 infection (COVID-19) is a risk factor for VTE; however, CDS developed before the COVID-19 pandemic may not accurately prognosticate VTE risk in children with COVID-19. This study's objective was to identify areas to improve thromboprophylaxis recommendations for children with COVID-19. METHODS: Inpatients with a positive COVID-19 test at admission were identified at a quaternary-care pediatric center between March 1, 2020 and January 20, 2022. The results of the institution's automated CDS thromboprophylaxis recommendations were compared to institutional COVID-19 thromboprophylaxis guidelines and to the actual thromboprophylaxis received. CDS optimization was performed to improve adherence to COVID-19 thromboprophylaxis recommendations. RESULTS: Of the 329 patients included in this study, 106 (28.2%) were prescribed pharmaco-prophylaxis, 167 (50.8%) were identified by the institutional COVID-19 guidelines as requiring pharmaco-prophylaxis, and 45 (13.2%) were identified by the CDS as needing pharmaco-prophylaxis. On univariate analysis, only age 12 years or more was associated with recipient of appropriate prophylaxis (OR 1.78, 95% CI: 1.13-2.82, p = .013). Five patients developed VTEs; three had symptoms at presentation, two were identified as high risk for VTE by both the automated and best practice assessments but were not prescribed pharmaco-prophylaxis. CONCLUSION: Automated thromboprophylaxis recommendations developed prior to the COVID-19 pandemic may not identify all COVID-19 patients needing pharmaco-prophylaxis. Existing CDS tools need to be updated to reflect COVID-19-specific risk factors for VTEs.

Inpatient Telehealth Experience of Patients With Limited English Proficiency: Cross-sectional Survey and Semistructured Interview Study.

BACKGROUND: Patients with limited English proficiency (LEP) are at a higher risk of poor health outcomes and are less likely to use telehealth than English-speaking patients. To date, there is no formal evaluation of inpatient (IP) telehealth user experience of patients and their families by language preference during visits with their clinicians. OBJECTIVE: This study aims to compare the experiences of English- and Spanish-speaking patients and their families using IP telehealth, as well as to evaluate the experience of Spanish interpreters providing services through IP telehealth. METHODS: We prospectively administered a survey to English- and Spanish-speaking patients and their families who used IP telehealth from October 1, 2020, to March 31, 2021. We performed semistructured phone interviews of hospital-based Spanish interpreters who provided services through IP telehealth. RESULTS: A total of 661 surveys were administered, with completion rates of 18% (112/621) in English and 62% (25/40) in Spanish. On a 10-point scale, the overall satisfaction of Spanish speakers (median 10, IQR 10-10) was higher than that of English speakers (median 9, IQR 8-10; P=.001). Both English- and Spanish-speaking patients used IP telehealth for visits with their primary IP care team, subspecialty consultants, and other clinicians. Hospital tablets were used more often than personal devices, and only English-speaking patients used personal laptops. Patients and their families encountered challenges with log-in, team coordination with multiple users, and equipment availability. Interpreters encountered challenges with audio and video quality, communication, safety, and Wi-Fi access. CONCLUSIONS: Both English- and Spanish-speaking patients reported high satisfaction using IP telehealth across multiple disciplines despite the workflow challenges identified by interpreters. Significant investment is needed to provide robust infrastructure to support use by all patients, especially the integration of multiple users to provide interpreter services for patients with LEP.

Changes Made to Orders Placed by Overnight Admitting Residents on Teaching Rounds the Next Day.

OBJECTIVES: Increased focus on health care quality and safety has generally led to additional resident supervision by attending physicians. At our children's hospital, residents place orders overnight that are not explicitly reviewed by attending physicians until morning rounds. We aimed to categorize the types of orders that are added or discontinued on morning rounds the morning after admission to a resident team and to understand the rationale for these order additions and discontinuations. METHODS: We used our hospital's data warehouse to generate a report of orders placed by residents overnight that were discontinued the next morning and orders that were added on rounds the morning after admission to a resident team from July 1, 2017 to June 29, 2018. Retrospective chart review was performed on included orders to determine the reason for order changes. RESULTS: Our report identified 5927 orders; 538 were included for analysis after exclusion of duplicate orders, administrative orders, and orders for patients admitted to non-Pediatric Hospital Medicine services. The reason for order discontinuation or addition was medical decision-making (n = 357, 66.4%), change in patient trajectory (n = 151, 28.1%), and medical error (n = 30, 5.6%). Medical errors were most commonly related to medications (n = 24, 80%) and errors of omission (n = 19, 63%). CONCLUSIONS: New or discontinued orders commonly resulted from evolving patient management decisions or changes in patient trajectory; medical errors represented a small subset of identified orders. Medical errors were often errors of omission, suggesting an area to direct future safety initiatives.

Pediatric Intern Clinical Exposure During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Pediatric health care encounters declined during the coronavirus disease 2019 (COVID-19) pandemic, and pediatric residency programs have adapted trainee schedules to meet the needs of this changing clinical environment. We sought to evaluate the impact of the pandemic on pediatric interns' clinical exposure. METHODS: In this retrospective cohort study, we quantified patient exposure among pediatric interns from a single large pediatric residency program at a freestanding children's hospital. Patient encounters and shifts per pediatric intern in the inpatient and emergency department settings were evaluated during the COVID-19 pandemic, from March to June 2020, as compared with these 3 months in 2019. Patient encounters by diagnosis were also evaluated. RESULTS: The median number of patient encounters per intern per 2-week block declined on the pediatric hospital medicine service (37.5 vs 27.0; P < .001) and intensive care step-down unit (29.0 vs 18.8; P = .004) during the pandemic. No significant difference in emergency department encounters was observed (63.0 vs 40.5; P = .06). The median number of shifts worked per intern per 2-week block also decreased on the pediatric hospital medicine service (10.5 vs 9.5, P < .001). Across all settings, there were more encounters for screening for infectious disease and fewer encounters for respiratory illnesses. CONCLUSIONS: Pediatric interns at the onset of the COVID-19 pandemic were exposed to fewer patients and had reduced clinical schedules. Careful consideration is needed to track and supplement missed clinical experiences during the pandemic.

Preserving privacy for pediatric patients and families: use of confidential note types in pediatric ambulatory care.

OBJECTIVE: This study evaluates and characterizes the use of a confidential clinic note type as part of the implementation of open notes at a free-standing children's hospital. We describe how this electronic health record feature which disables patient and family access to selected notes in the patient portal is used across our institution, which clinicians are using this feature, and the type of data our clinicians consider confidential. MATERIALS AND METHODS: Through retrospective chart review, we have evaluated the use of a confidential note type over a 1-year period. RESULTS: We identified 402 964 clinic notes created during a 1-year period, of which 9346 (2.3%) were flagged as confidential. Use of this confidential note type was associated with female patient sex and increase in patient age. It was used most frequently by a small subset of providers. 922 (83.8%) of 1100 notes manually reviewed contained sensitive information. Reasons for confidential notes varied, but patient's mental health was most commonly identified. DISCUSSION: Our data demonstrate variability in the use of a confidential note type across specialties, patient ages, and types of confidential information. This note type is frequently utilized by a subset of providers who often manage sensitive patient and parent information. As vendors and institutions enable open notes, thoughtful implementation and provider education surrounding the use of this confidential feature is needed. CONCLUSION: A confidential clinic note feature is an integral aspect of pediatric open notes implementation. This feature supports protection of confidential information pertaining to our patients and their caregivers.

Rapid Implementation of an Inpatient Telehealth Program during the COVID-19 Pandemic.

BACKGROUND: Relaxation of laws and regulations around privacy and billing during the COVID-19 pandemic provide expanded opportunities to use telehealth to provide patient care at a distance. Many health systems have transitioned to providing outpatient care via telehealth; however, there is an opportunity to utilize telehealth for inpatients to promote physical distancing. OBJECTIVE: This article evaluates the use of a rapidly implemented, secure inpatient telehealth program. METHODS: We assembled a multidisciplinary team to rapidly design, implement, and iteratively improve an inpatient telehealth quality improvement initiative using an existing videoconferencing system at our academic medical center. We assigned each hospital bed space a unique meeting link and updated the meeting password for each new patient. Patients and families were encouraged to use their own mobile devices to join meetings when possible. RESULTS: Within 7 weeks of go-live, we hosted 1,820 inpatient telehealth sessions (13.3 sessions per 100 bedded days). We logged 104,647 minutes of inpatient telehealth time with a median session duration of 22 minutes (range 1-1,961). There were 5,288 participant devices used with a mean of 3 devices per telehealth session (range 2-22). Clinicians found they were able to build rapport and perform a reasonable physical exam. CONCLUSION: We successfully implemented and scaled a secure inpatient telehealth program using an existing videoconferencing system in less than 1 week. Our implementation provided an intuitive naming convention for providers and capitalized on the broad availability of smartphones and tablets. Initial comments from clinicians suggest the system was useful; however, further work is needed to streamline initial setup for patients and families as well as care coordination to support clinician communication and workflows. Numerous use cases identified suggest a role for inpatient telehealth will remain after the COVID-19 crisis underscoring the importance of lasting regulatory reform.

Association of ventricular arrhythmia and in-hospital mortality in stroke patients in Florida: A nonconcurrent prospective study.

Stroke remains one of the leading causes of death in the United States. Current evidence identified electrocardiographic abnormalities and cardiac arrhythmias in 50% of patients with an acute stroke. The purpose of this study was to assess whether the presence of ventricular arrhythmia (VA) in adult patients hospitalized in Florida with acute stroke increased the risk of in-hospital mortality.Secondary data analysis of 215,150 patients with ischemic and hemorrhagic stroke hospitalized in the state of Florida collected by the Florida Agency for Healthcare Administration from 2008 to 2012. The main outcome for this study was in-hospital mortality. The main exposure of this study was defined as the presence of VA. VA included the ICD-9 CM codes: paroxysmal ventricular tachycardia (427.1), ventricular fibrillation (427.41), ventricular flutter (427.42), ventricular fibrillation and flutter (427.4), and other - includes premature ventricular beats, contractions, or systoles (427.69). Differences in demographic and clinical characteristics and hospital outcomes were assessed between patients who developed versus did not develop VA during hospitalization (χ and t tests). Binary logistic regression was used to estimate unadjusted and adjusted odds ratios and 95% confidence intervals (CIs) between VA and in-hospital mortality.VA was associated with an increased risk of in-hospital mortality after adjusting for all covariates (odds ratio [OR]: 1.75; 95% CI: 1.6-1.2). There was an increased in-hospital mortality in women compared to men (OR: 1.1; 95% CI: 1.1-1.14), age greater than 85 years (OR: 3.9, 95% CI: 3.5-4.3), African Americans compared to Whites (OR: 1.1; 95% CI: 1.04-1.2), diagnosis of congestive heart failure (OR: 2.1; 95% CI: 2.0-2.3), and atrial arrhythmias (OR: 2.1, 95% CI: 2.0-2.2). Patients with hemorrhagic stroke had increased odds of in-hospital mortality (OR: 9.0; 95% CI: 8.6-9.4) compared to ischemic stroke.Identifying VAs in stroke patients may help in better target at risk populations for closer cardiac monitoring during hospitalization. The impact of implementing methods of quick assessment could potentially reduce VA associated sudden cardiac death.

Forgotten goiter: Diagnosis and management. A case report and literature review.

INTRODUCTION: A mediastinal thyroid mass discovered years after a total thyroidectomy represents an unusual and uncommon clinical situation. Few cases have been reported and controversy exists regarding the etiology of this ectopic thyroid tissue as well as the optimal surgical approach for resection. We herein describe a case of a mediastinal thyroid goiter discovered five years after a total thyroidectomy. PRESENTATION OF CASE: A 54-year-old Hispanic female was diagnosed with a diffuse cervical goiter secondary to Hashimoto's Thyroiditis and subsequently underwent a total thyroidectomy. Five years later the patient had a chest X-ray as part of a preoperative evaluation for an unrelated and elective surgical procedure. Significant tracheal deviation was identified. A computed tomography scan was obtained and demonstrated a well encapsulated mass in the superior mediastinum resulting in tracheal deviation and compression. This "forgotten" goiter was successfully resected utilizing a standard cervical approach and the patient recovered uneventfully. DISCUSSION: A thyroid mass within the mediastinum following a total thyroidectomy is a condition often referred to as "forgotten goiter". Prior reported cases are few, and data is limited, with some uncertainty remaining as to the exact origin of this ectopic thyroid tissue. Possible etiologies include an incomplete removal of the thyroid gland during initial cervical thyroidectomy, or perhaps an autonomous intrathoracic goiter (AIG) - a thyroid gland located in the mediastinum, independent and with no parenchymatous or vascular connection with the cervical thyroid gland. CONCLUSION: A trans-thoracic or sternal splitting approach is generally not required for resection of a mediastinal goiter and our experience confirms that the case of the "forgotten goiter" can be safely approached through a cervical incision as well.