A Randomized Comparative Trial to Evaluate a PICU Navigator-Based Parent Support Intervention.

Provider status effort engaged on Capitol Hill

IntroductionFor every woman who dies during pregnancy and childbirth, many more suffer ill-health, the burden of which is highest in low-resource settings. We sought to assess the extent and types...

Title Assessing Maternal Morbidity in India, Pakistan, Kenya and Malawi. Background For every woman who dies during pregnancy and childbirth, many more suffer ill-health, the burden of which is highest in low- and middle-income countries. The PhD study sought to assess the extent and type of maternal morbidity in these settings. Methods A descriptive observational cross-sectional study was conducted to assess physical (infectious and medical/obstetric), psychological and social morbidity. Socio-demographic factors, education, socioeconomic status, reported symptoms, clinical examination and laboratory investigations, quality of life, and satisfaction with health were assessed. Relationships between morbidity and maternal characteristics were investigated using logistic regression analysis. Findings 11454 women were assessed in India (2099), Malawi (2923), Kenya (3145), and Pakistan (3287). Almost 3 out of 4 women had ≥1 symptom (73.5%), abnormalities on clinical examination (71.3%) or laboratory investigation (73.5%). In total, 9.0% of women had an identified infectious disease (HIV, malaria, syphilis or chest infection) and 23.1% had signs of early sepsis with an identifiable source of infection in 43%. HIV positive status was highest in Malawi (14.5%) as was malaria (10.4%). Overall, 47.9% of women were anaemic, 11.5% had other medical or obstetric conditions, 25.1% psychological and 36.6% social morbidity. Infectious morbidity was highest in Malawi (40.5%) and Kenya (38.5%), psychological and social morbidity was highest in Pakistan (47.3%, 60.2%). Morbidity was not limited to a core at risk group; only 1.2% had a combination of all four morbidities. Age, socioeconomic status, educational, previous pregnancies, and adverse maternal or neonatal outcomes were associated with different types of morbidity per country, but there was no consistent direction of strength of association. For each country, women with medical/obstetric morbidity was more likely to report psychological and infectious morbidity, apart from Malawi. Women with an infectious morbidity were more likely to report medical/obstetric, psychological and social morbidity in Pakistan and Malawi. Women with psychological morbidity were more likely to report social morbidity in Pakistan and Kenya. Conclusion Despite women reporting that they have a good quality of life and are satisfied with their health, there is evidence of a significant burden of infectious, medical/obstetric, psychological, and social morbidity in women during and after pregnancy. At present available antenatal and postnatal care packages do not include comprehensive screening for all forms of ill-health. This study demonstrates that women have health needs, beyond simply the physical aspects of health and includes psychological and social well-being. To ensure all women have the right to the highest attainable standard of health and well-being, current antenatal and postnatal care packages need to be adapted and improved to provide comprehensive, holistic care in a way that meets a woman’s health needs.

The impact of the PICU diary on post-intensive care syndrome in children and their parents: A pilot randomized controlled trial.

Glaucoma suspect was the most prevalent category in this study followed by glaucoma associated with acquired ocular anomaly and juvenile open-angle glaucoma. Primary congenital glaucoma was diagnosed in only 3% of the population studied. To describe the prevalence and clinical characteristics of childhood glaucoma diagnosed over a 10-year period among patients aged 18 years or below who were seen at a tertiary care children's hospital using the new Childhood Glaucoma Research Network classification system. Medical records of all patients aged 18 years or below (n=108) who were diagnosed with glaucoma between January 1, 2008 through September 30, 2018 were reviewed. Data collected included demographics (age at diagnosis, sex, and family history of glaucoma), intraocular pressure, disc-to-cup ratio, retinal nerve fiber layer thickness, and refractive errors. Clinical characteristics of each patient were evaluated according to the criteria established by Childhood Glaucoma Research Network. Categorical distributional equivalence comparisons were performed using the Pearson χ test. A P-value <0.05 was defined as statistically significant. A total of 108 patients with a diagnosis of childhood glaucoma or glaucoma suspect were included in this study. Sixty-four percent of these patients were males (P<0.0001). The mean age at the time of diagnosis was 7.07±5.4 years. "Glaucoma suspect" was the most prevalent category (46%, P=0.0002), followed by glaucoma associated with the acquired ocular anomaly (20%) and juvenile open-angle glaucoma (16%). Primary congenital glaucoma represented 3% and all these patients were males. Sixty-nine percent of the patients had bilateral involvement (P=0.0073). The highest intraocular pressure recorded in the study was 57 mm Hg, the largest cup-to-disc ratio was 0.96, and the lowest retinal nerve fiber layer measurement was 39 μm. Ninety-two percent of the patients had refractive errors and 85% of them had astigmatism. Establishing a pattern and the associated clinical characteristics of childhood glaucoma at tertiary care children's hospitals will help in developing collaborative research efforts and effective treatment/management strategies for children with these rare groups of disorders.

Enhancing communication between family members and health care team members within the pediatric intensive care unit (PICU) is a national clinical and research priority. Poor communication can increase patients’ length of stay, hospital costs, and the likelihood of delivering value-discordant care. Family members of PICU patients report numerous communication barriers, such as poor access to members of the health care team, inadequate care coordination, and infrequent clinician-initiated discussions. Despite these rec-ognized barriers, there is a salient lack of interventions to support communication between PICU family members and members of the health care team.To address this issue, the investigators studied the feasibility of implementing a navigator-based communication intervention called PICU Supports and assessed the responses of family members and clinicians to that intervention. PICU Supports comprises specific intervention components for the navigator, patients’ family members, and health care providers. The navigator’s intervention components included a rigorous navigator- training protocol; a standardized meeting-frequency protocol for the navigators, the family members, and the health care team members; tailored PICU-transition support for the family members; and a post-PICU discharge check-in. Family members’ intervention components included a parent-developed PICU information handbook, a bedside communication log, and bereavement packets for family members of decedents. Each week, members of the health care team reviewed a navigator-prepared document that included relevant psychosocial information and identified family needs. The investigators conducted this study at a university-based, tertiary-care children’s hospital with 76 PICU beds.Family members completed the same survey at enrollment, discharge, and 3 to 5 weeks after discharge. Some family members participated in an optional 1-on-1 semistructured audio interview at discharge. Thirty-five family members enrolled in the study. Family members reported that PICU Supports improved communication with members of the health care team, although no family members requested a family meeting. Opinions on the PICU handbook were mixed, as some family members were too overwhelmed to read the material. Family members and health care team members rarely used the bedside communication log. Overall, the health care team members found PICU Supports to be valuable, but they recommended improving the navigator’s integration with members of the health care team. The investigators concluded that PICU Supports was feasible to implement and research and that further refinement and testing of the intervention are warranted.Kelly N. Michelson, MD, MPH, lead author of the study, cites her prior research and personal clinical experiences as the motivation for the study. Originally, Dr Michelson had planned to develop a standardized approach to address end-of-life decision-making in the PICU. However, her preliminary work “highlighted the individual nuances and contextual issues that often influence decision-making” in the PICU. So rather than creating a standardized intervention, Dr Michelson concluded that critical care providers may benefit from “a malleable approach to decision-making that can easily be adapted to the individual needs of each family, patient, and situation.” She adds, “given the successful implementation of navigators in other settings, introducing a navigator into the PICU setting to individualize decision-making and psychosocial supports seems like the next natural step.”To assemble the team necessary to develop PICU Supports, Dr Michelson used “stakeholder-engaged comparative effectiveness research” as a guiding framework. “We identified 3 groups of stakeholders: parents of previously critically ill children, clinicians who care for and administrators who oversee the care of critically ill children, and clinical trials research experts.” The clinician stakeholder group included representatives from various medical specialties, nursing, social work, palliative care, spiritual care, and administration. Together, these 3 stakeholder groups developed the PICU Supports intervention and helped design the study.Dr Michelson contends that the “value of having such a large, multifaceted group is reflected in the comprehensive nature of the PICU Supports intervention,” and encourages “investigators to make that extra effort to engage” multidisciplinary groups during research. However, she admits that “coordinating such a large group presented some challenges.” Dr Michelson recalls difficulty scheduling meetings and “finding ways to keep the larger team engaged when there were no direct activities for them to comment on or participate in.” Nevertheless, she concludes: “I feel incredibly privileged to have had the opportunity to work with such a diverse and dedicated group of people.”Dr Michelson believes that although “we are still trying to determine the best way to support parents and families of critically ill children … the best approaches will ultimately require a team effort,” as many disciplines and professions influence the family experience within the PICU. She anticipates that “this work will help pediatric critical care teams develop strategies for bringing those group efforts together.” Dr Michelson humbly acknowledges that PICU Supports is “only one approach” that can be used to support families and clinicians and “the impact of this approach is still yet to be determined. But the idea that we need to find better, more efficient ways to individualize care for families, knowing the complexity of the care team and clinical challenges facing those in the PICU, is fundamental.”As clinicians and scientists conduct more research, prominent questions may arise. For example, Dr Michelson shares, “we were surprised to see so few parents interested in having family meetings because many experts tout their value.” She further acknowledges that research within the PICU can be difficult because “it serves a very heterogeneous population with different support needs.” As such, studies may focus on “very specific populations,” which “limits generalizability.” Alternatively, investigators may “create an option that could be adapted to different populations to maximize generalizability and scalability…. Perhaps, the best approach lies somewhere between those two extremes.”This feature briefly describes the personal journey and background story of the EBR article’s investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Kelly N. Michelson, MD, MPH, has been a pediatric critical care specialist for more than 15 years. However, another of her life’s passions is dance: “Dancing and the human body were always my passions.” In fact, she focused on dance between completing her undergraduate degree and entering medical school. “My dance career allowed me to travel nationally and internationally and to fulfill one of my childhood dreams. But I never let go of my dream to become a physician.”During her pediatric and critical care training, Dr Michelson “was drawn to the interesting pathophysiology and fast pace in the PICU.” She “was also amazed by the intense relationships that clinicians develop with parents of critically ill patients … [who are] facing their worst nightmare.” She says that these formative experiences “drove me to do the research that I do now.” Even today, Dr Michelson’s experiences as a pediatric intensivist remain central: “[they] shape how I think about supporting families of critically ill children and about the questions I try to address in my research.”

To describe the role of the hand-held otoscope combined with a flashscanner CO2 laser, OtoLAM (ESC/Sharplan, Yokneam, Israel), for pressure equalization tube (PET) insertion in an office setting. Prospective, multisite, clinical cohort trial (Institutional Review Board approved; informed consent) in the setting of pediatric otolaryngology outpatient departments at four tertiary care children's hospitals. Selected for the study were 54 patients (96 ears), ages 6 months to 23 years, who met standard indications for PET insertion using cold-knife myringotomy and tube insertion under general anesthesia. PETs were indicated for recurrent otitis media, chronic otitis media with effusion, and eustachian tube dysfunction-all unresponsive to medical therapy. Topical anesthesia was achieved with iontophoresis (n = 1) or topical anesthesia: 8% tetracaine on an Otowick (Xomed Surgical Products, Jacksonville, FL, catalogue No. 400141) against the tympanic membrane for 45 to 180 minutes (n = 53). Laser-assisted tympanic membrane fenestration was performed with the OtoLAM set at single pulse, 2.0- to 2.6-mm spot size, and between 3 and 18 W. Insertion of grommets was accomplished using the otomicroscope and an "alligator" microforceps. Restraints with papoose were used in 79% of children with a mean age of 34.4 months (SD = 60.9 mo). Clinical, parent/patient, and physician satisfaction and comparative cost impact outcomes are described. All ears but three (3%) underwent successful placement of a PET. Pain was described as "absent" in 39%, "present but tolerable" in 30%, and "severe" in 30% of children at the time of procedure; 5 minutes after the procedure pain was described as "absent" in 75%, "present but tolerable" in 22%, and "severe" in 3%. Tube plugging (3 of 74 available ears; 4%) or persistent otorrhea (1 of 74 ears; 1.4%) occurred infrequently at the 1-month follow-up. Before PET insertion, hearing loss was noted in 66% of cases (mild, 38%; moderate, 22%; and severe, 6%). Mild hearing loss was noted in only 8% and moderate hearing loss in 2% of 47 (50%) of the ears at the 3-month follow-up. Ninety-two percent of parents were highly satisfied with the procedure in preference to PETs in the operating room under general anesthesia, and 97% preferred OtoLAM with PET insertion, rather than further courses of antibiotics; only one parent would rather have had the PET insertion under general anesthesia. Cost savings to health care organizations, particularly payers, and to parents are substantial (32%-48%) and warrant attention. Cost to the physician is manageable only if an appropriate approach to the third party payers results in a substantial increase in reimbursements. The data indicate excellent clinical effectiveness, reduced risk, and high parent and physician satisfaction. Strong incentives for physicians to use this technique are in all stakeholders' best interests. These incentives need to evolve as soon as possible for the more widespread acceptance of OtoLAM with PET insertion in an office setting for appropriately selected patients.

A Review of Current Literature of Interest to the Office-Based Anesthesiologist.

Hospital readmissions in pediatrics are a severe, potentially avoidable problem of health systems. In our setting, there is little information about this topic. To estimate the rate of readmissions, the proportion of potentially preventable readmissions, and their associated characteristics. Cross-sectional study including hospital readmissions of patients aged 0-18 years, admitted to a tertiary care children's hospital between January 1st and December 31st, 2018. Readmissions were assessed as potentially preventable based on whether they were or not related to the previous admission. Out of 8228 hospital admissions recorded in the study period, the rate of readmissions for any cause was 10 % at 30 days and 7.1 % at 15 days. The proportion of readmissions classified as potentially preventable was 47.9 % at 30 days and 47.5 % at 15 days. No statistically significant differences were observed between readmissions at 30 and 15 days in terms of patient age, health insurance, presence of chronic disease or cause of readmission. The rate of hospital readmissions was 10 % at 30 days and 7.1 % at 15 days of discharge; almost half of them were considered potentially preventable.

Caregiving at the End of Life: Perceptions of Health Care Quality and Quality of Life Among Patients and Caregivers

A Fijian community affected by a cyclone was compared with an unaffected but similar community. Two months after the cyclone both psychological and physical morbidity was 2-3 times greater in the affected community than in controls. By the third month morbidity had resolved to levels similar to those in the unaffected population. Brief, catastrophic stress without loss of life appears to provoke psychological and physical morbidity of relatively brief duration.

Cardiac magnetic resonance (CMR) incorporates a field of view that has the potential to capture clinically relevant extracardiac findings (ECF); however, there has been minimal investigation of ECF prevalence in children's hospitals, where the patient population varies in age and diagnosis. We retrospectively reviewed consecutive, clinically indicated, CMR studies performed at a tertiary care children's hospital during a 1-year period from January 1 to December 31, 2019. ECFs were classified as significant or non-significant based on whether they were described in the final impression of the CMR report. A total of 851 distinct patients had a CMR study during the 1-year period. Mean age was 19.5 (range 0.2; 74.2) years. A total of 254 ECFs were present in 158 of the 851 studies (18.6%) with 9.8% of all studies having significant ECFs. A total of 40.2% of ECFs were previously unknown and 9.1% (23/254) of ECFs included further recommendations (2.1% of all studies). ECFs were most often found in the chest (48%) or abdomen/pelvis (46%). Three patients were incidentally found to have malignancy (renal cell, thyroid, and hepatocellular carcinoma). Comparing studies with significant ECFs to the group without, CMR indications for biventricular CHD (43% vs 31%, p = 0.036), single ventricle CHD (12% vs 3.9%, p = 0.002), and aortopathy/vasculopathy (16% vs 7.6%, p = 0.020) were more common. The odds of significant ECF increased with increasing age (OR 1.82, 95% CI 1.10-3.01) and increased most notably between ages 14 to 33years old. Recognition of the high percentage of ECFs remains important for timely diagnosis of these incidental findings.

Bacteriology of the paranasal sinuses in pediatric cystic fibrosis patients

Access to neurology services is important for children's well-being. We sought to evaluate the effects of telehealth on pedi-atric neurology appointment outcomes for children. Using electronic health record (EHR) data, information about children with pediatric neurology appointments in a tertiary care children's hospital in North Carolina was collected. Appointment outcomes (completion, cancellation, and no-show rates) were calculated for children who had a neurology appointment scheduled both in the pre-pandemic (March 10, 2019, to March 9, 2020) and pandemic (March 10, 2020, to March 9, 2021) periods. "Telehealth user" was a child who had at least one telehealth appointment scheduled between March 10, 2020, and March 9, 2021. In bivariate and multivariate analyses, we compared appointment outcomes for telehealth users and non-users. EHR data were limited to a single institution and could have missed children's clinical encounters elsewhere. Since this study used secondary data that were not collected for research purposes, it is possible that there were unmeasured confounders. Because of the observational nature of the study, the association between telehealth use and appointment outcomes does not indicate causation. A total of 2110 children had 11,194 pediatric neurology appointments scheduled. Telehealth users compared with non-users were more likely to be White, non-Hispanic, have private insurance, and live farther from the children's hospital. There was a statistically sig-nificant decrease in completion (66% versus 57%) and increase in cancellation (27% versus 33%) and no-show (7% versus 10%) rates in the pandemic when compared to the pre-pandemic period. In the pre-pandemic period, telehealth user and non-user groups had similar cancellation and no-show rates. In the pandemic period, there was a statistically significant decrease in cancellation and no-show rates in the telehealth user group when compared to the non-user group. Pediatric neurology outpatient clinic visits decreased substantially during the pandemic. Telehealth mitigated these problems. Children belonging to a minority race/ethnicity are less likely to use telehealth, increasing their risk of poor access to neurology services.

Freestanding children's hospitals may lack resources, especially surgical manpower, to meet American College of Surgeons trauma center criteria, and may organize trauma care in alternative ways. At a tertiary care children's hospital, attending trauma surgeons and anesthesiologists took out-of-hospital call and directed initial care for only the most severely injured patients, whereas pediatric emergency physicians directed care for patients with less severe injuries. Survival data were analyzed using TRISS methodology. A total of 903 trauma patients were seen by the system during the period 10/1/96-6/30/01. Median Injury Severity Score was 16, and 508 of patients had Injury Severity Score > or =15. There were 83 deaths, 21 unexpected survivors, and 13 unexpected deaths. TRISS analysis showed that z-score was 4.39 and W-statistic was 3.07. Mortality outcome from trauma in a pediatric hospital using this alternative approach to trauma care was significantly better than predicted by TRISS methodology.