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Treatment of multisystem inflammatory syndrome in children (MIS-C) can require significant critical care resources. Our aim is to alert mixed pediatric and adult hospitals worldwide of the possibility that pediatric and adult patients may simultaneously require cannulation to extracorporeal membrane oxygenation (ECMO) for MIS-C and severe COVID-19. We conducted a retrospective review of operations required to treat cardiogenic shock in 3 pediatric patients with a diagnosis of MIS-C admitted to a single medium-sized pediatric referral center located within a large academic medical center over a 14-day period. At this time, a large number of adult patients required ECMO for severe COVID-19 at our institution. Of the 11 pediatric patients who presented with MIS-C during the first surge of 2020, 2 patients required cannulation to venoarterial extracorporeal membrane oxygenation (VA-ECMO), and a third patient developed a life-threatening arrhythmia requiring transfer to a neighboring institution for consideration of VA-ECMO when our institution's ECMO capacity had briefly been reached. Pediatric referral centers located within institutions providing ECMO to adult patients with severe COVID-19 may benefit from frequent and direct communication with their adult and regional colleagues to devise a collaborative plan for safe and timely provision of ECMO to patients with MIS-C as the ongoing pandemic continues to consume this limited, lifesaving resource.

This study aimed to assess whether elevations in cardiac biomarkers are associated with pediatric cardiac diagnoses in the era of COVID-19 and multisystem inflammatory syndrome in children (MIS-C).This single-center retrospective study analyzed children with a troponin drawn in the emergency department or inpatient unit between April 21 and December 31, 2020. The primary outcome was the presence of a cardiac diagnosis or MIS-C. Relationships among demographics, complaint, cardiac diagnostics, and cardiac biomarkers were analyzed.Four hundred eighty-six patients (mean ± SD; age 13.1 ± 7.8 years; 46.7% women) met inclusion criteria, for whom a cardiac diagnosis (excluding MIS-C) was made in 27 (5.6%) patients, with MIS-C diagnosed in 14 (2.9%) patients. The sensitivity and specificity of an elevated initial high-sensitivity troponin T (hsTropT) value (14 ng/L) in predicting the composite outcome of a cardiac diagnosis or MIS-C were 54% and 89%, respectively. Four percent of patients with negative initial troponin values were found to have a cardiac diagnosis or MIS-C. Multivariable regression analysis demonstrated that elevated hsTropT (14 ng/L; odds ratio [OR] [95% confidence interval]: 4.9 [1.70-14.0]) and elevated N-terminal pro B-type natriuretic peptide values (500 pg/mL; 6.4 [2.01-20.1]) were associated with increased odds of a cardiac diagnosis or MIS-C.Children with elevated cardiac biomarkers have increased odds of a cardiac diagnosis or MIS-C and warrant workup regardless of indication for testing. Although a negative hsTropT may reassure providers, further investigation is critical in developing algorithms to reliably exclude cardiac disease.

OBJECTIVES Necrotizing enterocolitis (NEC) is a severe intestinal inflammatory disease and a leading cause of morbidity and mortality in NICUs. Management of NEC is variable because of the lack of evidence-based recommendations. It is widely accepted that standardization of patient care leads to improved outcomes. This quality improvement project aimed to decrease variation in the evaluation and management of NEC in a Level IV NICU. METHODS A multidisciplinary team investigated institutional variation in NEC management and developed a standardized guideline and electronic medical record tools to assist in evaluation and management. Retrospective baseline data were collected for 2 years previously and prospectively for 3.5 years after interventions. Outcomes included the ratio of observed-to-expected days of antibiotics and nil per os (NPO) on the basis of the novel guidelines and the percentage of cases treated with piperacillin/tazobactam. Balancing measures were death, surgery, and antifungal use. RESULTS Over 5.5 years, there were 124 evaluations for NEC. Special cause variation was noted in the observed-to-expected antibiotic and NPO days ratios, decreasing from 1.94 to 1.18 and 1.69 to 1.14, respectively. Piperacillin/tazobactam utilization increased from 30% to 91%. There were no increases in antifungal use, surgery, or death. CONCLUSIONS Variation in evaluation and management of NEC decreased after initiation of a guideline and supporting electronic medical record tools, with fewer antibiotic and NPO days without an increase in morbidity or mortality. A quality improvement approach can benefit patients and decrease variability, even in diseases with limited evidence-based standards.

OBJECTIVES: Given the significant overlap of multisystem inflammatory syndrome in children (MIS-C) with other common childhood illnesses presenting to the emergency department, extensive workup of this syndrome has become necessary. Nevertheless, little has been published on the factors differentiating MIS-C from other conditions in the acute care setting. We investigated differences in presentation and laboratory studies between suspected versus confirmed MIS-C patients. METHODS: This was a retrospective cohort study on patients 21 years or younger undergoing investigation for possible MIS-C at a single institution between April 21 and July 1, 2020. The primary outcome was diagnosis of MIS-C or an alternative final diagnosis. Clinical features and laboratory findings from initial presentation were collected and analyzed. RESULTS: A total of 106 patients (median, 4 years; 55.7% male) were included, of whom 17 (16%) of 106 met the criteria for MIS-C. Multisystem inflammatory syndrome in children patients were significantly more likely to report a coronavirus disease 2019 exposure (odds ratio (OR), 13.17 [3.87-44.9]), have gastrointestinal symptoms (OR, 3.81 [1.02-14.19]), and have a significantly higher odds of having abnormal laboratory values including high-sensitivity troponin T (OR, 13 [4.0-42.2]), N-terminal B-type natriuretic peptide (OR, 8.4 [2.3-30.1]), D-dimer (OR, 13 [1.6-103]), and ferritin (OR, 7.8 [2.2-27.2]). There were also differences between groups in inflammatory markers: C-reactive protein (median, 134.45 mg/L vs 12.6 mg/L; P < 0.05) and procalcitonin (1.71 ng/mL vs 0.14 ng/mL; P < 0.001). CONCLUSIONS: Higher elevations in key laboratory studies may help to distinguish between MIS-C patients and non-MIS-C patients presenting to the emergency department.

To paraphrase Lewis Carroll’s poem “The Walrus and the Carpenter” from his Through the Looking Glass, “The time has come to talk of many things.” Not as the Walrus did in the nursery rhyme, “of sho...

It took millennia for the medical community to recognize that the Hippocratic insistence on “the physician knows best” was an inadequate approach to medicine. During a pandemic of unprecedented pro...

This paper examines and critiques the ethical issues in postmortem sperm retrieval and the use of postmortem sperm to create new life. The article was occasioned by the recent request of the parents of a West Point cadet who died in a skiing accident at the Academy to retrieve and use his sperm to honor his memory and perpetuate the family name. The request occasioned national media attention. A trial court judge in New York in a two-page order authorized both the retrieval and use of the postmortem sperm.

The opening sentence of Christopher Meyers’ Target Article is “Lying to one’s patient is wrong” (Meyers 2021). The author continues, “This truism is one that bioethicists have heartedly endorsed fo...

Positive toxicology testing at delivery can have enormous consequences for birthing persons and their families, including charges of child abuse or neglect and potential loss of custody for the birthing parent. Therefore state and national guidelines stipulate that, clinicians must obtain consent before toxicology testing at delivery.This study aimed (1) to determine clinician documentation of patient consent for peripartum toxicology testing and (2) to characterize the extent to which patient and hospital characteristics were associated with documented consent.This was a retrospective cohort of individuals who underwent toxicology testing within 96 hours of delivery between April 2016 and April 2020 at 5 affiliated hospitals across Massachusetts. Medical records were reviewed for documentation of clinician intent to obtain maternal toxicology, testing indication, verbal consent to testing, and child protective services involvement. Hierarchical multivariable logistic regression was used to examine the association between patient and hospital characteristics and documentation of verbal consent.Among 60,718 deliveries, 1562 maternal toxicology tests were obtained. Verbal consent for testing was documented in 466 cases (29.8%). Documented consent was lacking across most demographic groups. Consent was no more likely to be documented when a report was filed with child protective services and less likely in cases where the birthing parent lost custody before discharge (P=.003). In our multivariable model, consent was least likely to be documented when a maternal complication (abruption, hypertension, preterm labor, preterm premature rupture of membranes, or intrauterine fetal demise) was the indication for testing (adjusted odds ratio, 0.46; 95% confidence interval, 0.28-0.76). Verbal consent was twice as likely to be documented in delivery hospitals with established consent policies (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.37).Consent for toxicology testing at delivery seemed to be infrequently obtained on the basis of clinician documentation. Provider education and hospital policies for obtaining informed consent are needed to protect the rights of birthing individuals.

OBJECTIVES: To explore PICU patients’ experiences and perceptions through their drawings with explanatory narratives. METHODS: Single-center prospective study in a 14-bed PICU in a tertiary care, academic-affiliated hospital. Pediatric patients age 6 to 17 years admitted to the PICU were approached to participate within 12 hours of transfer out of the PICU. Patients completed a brief study interview to identify the best and worst things about their PICU experience. Patients were asked to draw a picture of their experiences and then explain their drawings to study staff. RESULTS: Forty patients (median age 11 [6–17] years) agreed to participate. The median length of PICU stay was 2 days. The best aspects of the PICU stay included staff (25%), entertainment devices (15%), and food (13%). The worst aspects of the PICU stay that were reported were the intravenous line (25%), alarms (10%), and physical discomfort (10%). The most common elements in drawings were self-depictions (88%), monitors (53%), the intravenous line (50%), registered nurses (35%), and television (33%). Patient narratives related to their drawings provided additional insights regarding patient experiences in the PICU and identified various coping mechanisms used by patients to adapt to their experiences. CONCLUSIONS: Drawing, along with explanation, enables patients admitted to a PICU to disclose additional unique descriptive information about their experiences as patients. Facilitating this mode of communication may increase providers’ awareness of positive and negative aspects of a PICU admission and may be used to improve pediatric patients’ experiences in the hospital setting.

Despite the aligned histories, development, and contemporary practices, today, pediatric anesthesiologists are largely absent from pediatric intensive care units. Contributing to this divide are deficits in exposure to pediatric intensive care at all levels of training in anesthesia and significant credentialing barriers. These observations have led us to consider, does the current structure of training lead to the ability to optimally innovate and collaborate in the delivery of pediatric critical care? We consider how redesigning the pediatric critical care training pathway available for pediatric anesthesiologists may improve care of children both in and out of the operating room by facilitating further sharing of skills, research, and clinical experience. To do so, we review the nuances of both training tracts and the potential benefits and challenges of facilitating greater integration of these aligned fields.

Foreign body ingestion (FoBI) is an important source of morbidity and mortality in the pediatric population. Patients with intellectual disabilities (ID) are at increased risk of FoBI, likely due to the known association between ID and increased rates of pica. In this report, we present the case of a 15-year-old female patient with autism spectrum disorder (ASD) and ID who presented to the emergency department with fever, drooling, and respiratory failure. She required intubation for airway management. A diagnosis of FoBI was made after striking CT images revealed an entire graphite pencil in her esophagus, causing perforation of the retropharyngeal space. Her recovery course was complicated. Shortly after discharge, the patient was readmitted with repeat FoBI and another significant esophageal injury. Patients with ID who require surgery due to FoBI are at higher risk of complications and often require prolonged hospitalizations compared to their neurotypical peers. Prevention of FoBI in patients with ID constitutes an important aspect of clinical care and requires efforts toward achieving a balance between patient safety and autonomy.

Given the significant overlap of multisystem inflammatory syndrome in children (MIS-C) with other common childhood illnesses presenting to the emergency department, extensive workup of this syndrome has become necessary. Nevertheless, little has been published on the factors differentiating MIS-C from other conditions in the acute care setting. We investigated differences in presentation and laboratory studies between suspected versus confirmed MIS-C patients.This was a retrospective cohort study on patients 21 years or younger undergoing investigation for possible MIS-C at a single institution between April 21 and July 1, 2020. The primary outcome was diagnosis of MIS-C or an alternative final diagnosis. Clinical features and laboratory findings from initial presentation were collected and analyzed.A total of 106 patients (median, 4 years; 55.7% male) were included, of whom 17 (16%) of 106 met the criteria for MIS-C. Multisystem inflammatory syndrome in children patients were significantly more likely to report a coronavirus disease 2019 exposure (odds ratio (OR), 13.17 [3.87-44.9]), have gastrointestinal symptoms (OR, 3.81 [1.02-14.19]), and have a significantly higher odds of having abnormal laboratory values including high-sensitivity troponin T (OR, 13 [4.0-42.2]), N-terminal B-type natriuretic peptide (OR, 8.4 [2.3-30.1]), D-dimer (OR, 13 [1.6-103]), and ferritin (OR, 7.8 [2.2-27.2]). There were also differences between groups in inflammatory markers: C-reactive protein (median, 134.45 mg/L vs 12.6 mg/L; P0.05) and procalcitonin (1.71 ng/mL vs 0.14 ng/mL; P0.001).Higher elevations in key laboratory studies may help to distinguish between MIS-C patients and non-MIS-C patients presenting to the emergency department.

The objective of this study was to describe the clinical characteristics and outcomes of adult coronavirus disease 2019 (COVID-19) patients admitted to a pediatric intensive care unit (PICU), with assessment of respiratory clinical severity and outcomes when cared for by pediatric intensivists utilizing specific care processes. We conducted a retrospective cohort study of adult patients admitted to the 14-bed PICU of a quaternary referral center during the COVID-19 surge in Boston between April and June 2020. A total of 37 adults were admitted: 28 tested COVID-19 positive and 9 tested COVID-19 negative. Of the COVID-19-positive patients, 21 (75%), were male and 12 (60.7%) identified as Hispanic/Latino. Comorbidities in the patients included diabetes mellitus (39.3%), hyperlipidemia (39.3%), and hypertension (32.1%). Twenty-four (85.7%) required mechanical ventilation, in whom the lowest median ratio of arterial oxygen partial pressure to fractional inspired pressure was 161.5 (141.0 to 184.5), the median peak positive end-expiratory pressure (PEEP) was 14 (12.0 to 15.8) cmH2O and 15 (62.5%) underwent an optimal PEEP maneuver. Twelve (50%) patients were proned for a median of 3.0 (3.0 to 4.8) days. Of the 15 patients who were extubated, 3 (20%) required reintubation. Tracheostomy was performed in 10 patients: 3 after extubation failure and 7 for prolonged mechanical ventilation and weakness. Renal replacement therapy was required by 4 (14.3%) patients. There were 2 (7.1%) mortalities. We report detailed clinical outcomes of adult patients when cared for by intact pediatric critical care teams during the COVID-19 pandemic. Good clinical outcomes, when supported by adult critical care colleagues and dedicated operational processes are possible.

Lung transplant is a potential life-lengthening option for individuals with cystic fibrosis (CF) and advanced lung disease. However, referral for transplant evaluation is not made for the majority of patients with CF with low lung function who die each year.1 Recently published consensus guidelines from the CF Foundation identify early transplant discussion as a critical approach to optimise access to this treatment option.2 This quality improvement (QI) intervention sought to improve education of patients with CF regarding transplant by increasing the frequency of outpatient CF clinic visits in which transplant is discussed with patients with low lung function. The setting for the QI initiative was the paediatric CF Centre at Massachusetts General Hospital. Strategies included: (1) Assembly of a multidisciplinary QI team including nursing, social work, CF providers and a transplant physician, (2) Analysis of the baseline frequency of transplant discussion between CF providers and patients with low lung function (eg, forced expiratory volume in 1 s (FEV1) ≤50%-predicted), (3) Process mapping steps to lung transplant discussion during clinic visits, (4) Survey of CF providers (n=3) to identify specific barriers to discussion in patients with low lung function, (5) Survey of patients with CF (n=6) regarding optimal timing for initial discussion, (6) Brainstorming of potential interventions using a priority pay-off matrix, (7) Creation of a web-based intervention and patient education material, and (8) Postintervention data collection and analysis using standard statistics and QI methodology. The project was undertaken as a QI initiative and was not formally supervised by the institutional review board of Mass General Brigham per their policies. Patients were involved in project design through individual interview and survey which guided the intervention. Baseline data revealed 17 patients with CF with an FEV …

Background/Objective Access to a firearm is a significant risk for completed suicide or homicide. We sought to increase the rate of screening for access to firearms in patients who presented to the emergency department with suicidal or homicidal ideation or suicide attempt through the use of quality improvement methodology. Methods Patient records were eligible for inclusion if the child was under the age of 19 and presented to the emergency room of our tertiary medical center with a diagnosis of suicidal ideation, homicidal ideation, or suicide attempt. Records were manually reviewed for demographic information and documentation of screening for access to firearms. A baseline survey of the pediatric residents was completed to identify perceived barriers to screening for access to firearms. Subsequently, three “Plan, Do, Study, Act” (PDSA) cycles consisting of a noon conference, a dedicated grand rounds, and an electronic health record template were completed. Results During the baseline and study period, 501 patients met inclusion criteria. Forty-one of sixty-six (62.1%) residents completed a baseline survey and identified barriers to screening. There was no significant increase in screening following the first or second PDSA cycles. Following the third PDSA cycle, screening rates increased from 4% to 34%. Conclusions Quality improvement methodology can be used to increase the rates of screening for access to firearms in high-risk patients. Further work is necessary to identify additional strategies to further increase screening rates.

Multiple integrated health systems use frontline staff training in quality and process improvement, although the optimal method to determine training success remains unknown. The authors assessed the Partners Clinical Process Improvement Leadership Program's short-term impact by evaluating data in project presentations during 14 courses between 2010 and 2016. Long-term impact was assessed via a graduate survey. Among 262 interprofessional teams, 180 (69%) achieved short-term improvement, including 78 (30%) achieving and 102 (39%) demonstrating improvement toward their project goal. Projects implementing ≥2 interventions were more likely to succeed. Of 231 graduates surveyed, 79% reported the ability to lead and 67% reported actual work on additional quality improvement projects. Ninety-seven percent of alumni reported a positive career impact. Hospital leadership support of clinical process improvement training meets short-term improvement needs and promotes long-term capacity for learning health systems.

The healthcare industry generates significant waste and carbon emissions that negatively impact the environment. Intensive care units (ICU) are a major contributor to the production of waste, due to patient complexity and needs requiring extensive equipment, cleaning practices and pre-emptive supplies. To quantify the extent of the problem, health care professionals collected all unused medical supplies destined to be discarded over three one-week periods in a paediatric intensive care unit, weighed the items, and created an inventory. This article argues for greener hospital standards and provides a specific example of a project framework to reduce disposable waste with the hope that others can embark on similar initiatives for a more ethical and sustainable future for hospitals. Healthcare facilities must not just meet short-sighted safety standards of the now. In order to be a virtuous organization, one must consider all implications of daily decisions, including disposable supplies and cleaning.

Repurposing a Pediatric ICU for Adults A Boston hospital transformed its pediatric ICU to treat adult patients. Preserving the original PICU team minimized unnecessary changes to personnel and the ...

Background: Standardized volume dosing of 23.4% hypertonic saline (HTS) exists for adults, but the concentration, dosing and administration of HTS in pediatrics is variable. With emerging pediatric experience of 23.4% HTS, a standard volume dose approach may be helpful. Objective: To describe initial experience with a standardized 23.4% HTS weight-based volume dosing protocol of 10, 20, or 30 mL in the pediatric intensive care unit. Methods: Standard volume doses of 23.4% HTS were developed from weight dosing equivalents of 3% HTS. Pre and post sodium and intracranial pressure (ICP) measurements were compared with paired t-test or Wilcoxon rank-sum test. The site of administration and complications were noted. Results: A total of 16 pediatric patients received 37 doses of 23.4% HTS, with the smallest patient weighing 11 kg. For protocol compliance, 17 doses (46%) followed recommended dosing, 19 were less volume than recommended (51%), and 1 dose (3%) was more than recommended. Mean increase in sodium was 3.5 mEq/L (95% CI = 2-5 mEq/L); P < 0.0001. The median decrease in ICP was 10.5 mm Hg (interquartile range [IQR] 8.3-19.5) for a 37% (IQR 25%-64%) reduction. Most doses were administered through central venous access, although peripheral intravenous administrations occurred in 4 patients without complication. Conclusion and Relevance: Three standard-volume dose options of 23.4% HTS based on weight increases sodium and reduces ICP in pediatric patients. Standard-volume doses may simplify weight-based dosing, storage and administration for pediatric emergencies, although the optimum dose, and safety of 23.4% HTS in children remains unknown.

With increasing focus in the last decade on post–cardiac arrest care in pediatrics, return of spontaneous circulation, survival rates, and neurologic outcome have improved. As part of this postarrest care, both the American Heart Association and the American Academy of Neurology state it is reasonable to consider targeted temperature management in pediatric comatose patients, although this care is challenging and time sensitive, with many gaps in knowledge remaining. Many pediatric patients will still not survive or will suffer severe neurocognitive impairment despite the therapeutic arsenal provided. Adult guidelines suggest providing postarrest supportive care and limiting prognosis discussions with families until after 72 hours of therapy, but pediatric clinicians are advised to consider a multitude of factors given the lack of data. What, then, should clinicians do if family members of a patient who has been resuscitated request the withdrawal of all life support in the 24 hours immediately postarrest? In this Ethics Rounds, we present such a case and the responses of different clinicians and bioethicists.

Purpose: Training clinical and supportive staff in quality improvement (QI) theory and use of QI tools has the potential to improve oncology care delivery. We report our combined experience of providing training to oncologists in a variety of local settings and assess the effect of the training on individual participants and for institutions. Methods: Multidisciplinary oncology teams at a comprehensive cancer center, an academic medical center, and community practices were led through experiential QI training that spanned several months. The curriculum included didactic training sessions that attendees applied to their local project-based work and that required plan-do-study-act cycles. The curriculum was adapted to the smaller practice setting through use of a workbook and a reduced focus on quantitative methods. All teams were supported by coaches and provided final presentations to leadership. The self-rated abilities of trainees to use 15 QI tools were assessed with a pre/post training survey that had five response categories (information, skill, knowledge, understanding, and wisdom). Local institutional and external project presentations were tracked. Results: During 7 years, 129 trainees participated in 56 QI projects. All of the 15 QI tools had 80% of trainees rate themselves in the top three categories (knowledge, understanding, and wisdom) after the training; none met this threshold before. Multiple projects were presented in institutional and external settings. Most projects targeted three of the four domains of the ASCO Quality Oncology Practice Initiative certification program standards. Conclusions: We implemented and sustained QI training programs in a variety of cancer delivery settings. The flexible training model should be easily adoptable by others.

"Compassion and mercy" are important values for humanizing medicine. There are limits, however, in their ability to help resolve disputes between physicians and families regarding appropriate end-of-life care. The recent cases of Charlie Gard and Alfie Evans in England highlight the issue. The English courts resolve such conflicts by an independent assessment of a court. The American judicial system does not share the centralized system of the English courts. In the United States Federal structure some 50 state legislatures and 50 state court systems go their separate ways. The result is differing, frequently conflicting, standards. We explore possible ways to avoid court involvement in the American context for resolving such disputes within the patient-physician relationship.

Safety assessment codes (SACs) are one method to evaluate adverse events and determine the need for a root cause analysis. Few facilities currently use SACs, and there is no literature examining their interrater reliability. Two independent raters assigned frequency, actual harm, and potential harm ratings to a sample of patient safety reports. An actual and potential SAC were determined. Percent agreement and Cohen's κ were calculated. Substantial agreement existed for the actual SAC (κ = 0.626, P < .001), fair agreement for the potential SAC (κ = 0.266, P < .001), and low agreement for potential harm (κ = 0.171, P = .002). Although there is subjectivity in all aspects of assigning SACs, the greatest is in potential severity. This presents a problem when using the potential SAC and is in agreement with previous literature showing significant subjectivity in determining potential harm. An operational framework is needed to strengthen reliability.

The opinion of Mr. Justice Francis of the English High Court which denied the parents of Charlie Gard, who had been born with an extremely rare mutation of a genetic disease, the right to take their child to the United States for a proposed experimental treatment occasioned world wide attention including that of the Pope, President Trump, and the US Congress. The case raise anew a debate as old as the foundation of Western medicine on who should decide and on what standard when there is a conflict between a family and the treating physicians over a possible treatment. This paper will explore the different approaches of the British and American courts on the issue and the various proposals from that of John Rawls in his A Theory of Justice to a processed-based approach for resolving such disputes. As carefully crafted as the opinion of Mr Justice Nicholas Francis in the Gard case proved to be, it left commentators unsatisfied. A widespread criticism, captured in an article by Michael Dougherty in The National Review was for the state to ‘get out of the way of the parents trying to act in the best interests of the child’.1 Although he conceded the parents could be adding to the suffering of the child by taking Charlie to America for an experimental therapy and agreed that such a choice ‘may be the wrong decision,’ in Dougherty’s view, it should still be ‘their decision’. Dougherty’s stand was the popular response to the question of ‘Who should decide?’ It fails, however, to propose any rationale for the decision. It provided no norms, no standards and no guidelines for the parents. Their motive could equally well be indifference to the suffering of the child as concern for his well-being. Furthermore, even good, loving parents may …

Objective While the electronic health record (EHR) has become a standard of care, pediatric patients pose a unique set of risks in adult-oriented systems. We describe medication safety and implementation challenges and solutions in the pediatric population of a large academic center transitioning its EHR to Epic. Methods Examination of the roll-out of a new EHR in a mixed neonatal, pediatric and adult tertiary care center with staggered implementation. We followed the voluntarily reported medication error rate for the neonatal and pediatric subsets and specifically monitored the first 3 months after the roll-out of the new EHR. Data was reviewed and compiled by theme. Results After implementation, there was a 5-fold increase in the overall number of medication safety reports; by the third month the rate of reported medication errors had returned to baseline. The majority of reports were near misses. Three major safety themes arose: (1) enterprise logic in rounding of doses and dosing volumes; (2) ordering clinician seeing a concentration and product when ordering medications; and (3) the need for standardized dosing units through age contexts created issues with continuous infusions and pump library safeguards. Conclusions Future research and work need to be focused on standards and guidelines on implementing an EHR that encompasses all age contexts.

The widely publicized British case of Charlie Gard became an international cause célèbre when the treating physicians petitioned the British courts to prevent the parents from taking their dying child to America where a physician held out promise of an unproven experimental therapy. The case became more sensationalized when the press reported that Pope Francis had intervened in the case against the position of the Vatican’s Academy for Life on the appropriate response to a patient with a lethal genetic disorder for which there was no known treatment. A review of the centuries-long teaching of Catholic moral theology on care of the dying demonstrates that the pastoral concern of Pope Francis for the grieving parents did not signal a change in church teaching on the care of the dying patient or reveal a disagreement between Pope Francis and the Academy for Life’s position on the appropriate care of Charlie Gard.

When asked how we became experts in a field that fifty years ago did not exist, it was not that we identified the issues in bioethics and presented solutions. Rather we stood on the shoulders of so...

Dicephalic, dithoracic, omphalo-ischiopagus 22-month-old conjoined twins were evaluated in the pediatric surgery clinic. Twin A was smaller and less active than Twin B; imaging studies revealed complex congenital heart disease. Management decisions were made.

Objective: A child’s pediatric intensive care unit (PICU) admission may have wide-ranging family implications. We assessed nonmedical out-of-pocket expenses (NMOOPEs) and disruptions in work and normal life for parents with a child admitted to the PICU for at least 2 days with acute, new onset, or exacerbation of a critical condition. Design: We conducted a prospective, single-center study; administered a daily verbal response survey on NMOOPEs; stratified families by annual income ($100 000); and calculated daily expenditures (DEs), estimated daily budgets (DBs), and percentage of NMOOPEs (%DE/DB). We used a modified caregiver version of the Work Productivity and Activity Impairment Scale to assess the impact of PICU admission on work-related and normal life activities. Setting: The PICU in an academic, tertiary medical center in the United States. Patients: Patients admitted to PICU. Interventions: None. Measurements and Main Results: The study included 38 families, with median length of PICU stay of 3 days (range 3-13). The mean total NMOOPE was $127 ± $107 (range $5-$511). Financial impact of DB in the 3 annual income groups ranged from 0% to 136% (median 36%), 5% to 18% (median 10%), and 4% to 39% (median 16%), respectively. Total work absenteeism for cohort was 78 days. High levels of distraction were reported in working families, and normal daily activities were interrupted or suspended. Conclusions: PICU hospitalization results in a range of direct NMOOPEs of varying burden on families and additional work productivity impact. Further research to understand the array of financial implications on families and additional mitigation strategies are needed.

The children were nestled all snug in their beds.While visions of sugar-plums danced in their heads.Clement Moore's cherished ‘Twas the Night Before Christmas captures the hopes, dreams and visions...

A Boy with Severe Anemia A 20-month-old boy was admitted to the hospital because of severe anemia. On examination, tachycardia, tachypnea, hepatosplenomegaly, multiple cafe au lait skin macules, an...

Objective Primary objective is to determine the rate of intubation with inappropriately sized endotracheal tubes (ETTs) in a pediatric intensive care unit (PICU) in El Salvador. Secondary objective is to determine effectiveness of a video-based curriculum to teach local providers on pediatric advanced airway management and surgical approach to patients requiring airway reconstruction. Methods Data for 296 intubated pediatric patients was collected over a six month period in a 16-bed PICU in El Salvador. Results of a learning behavior assessment survey completed by local healthcare workers informed a curriculum to complement on-site education during annual surgical airway mission trips. The video-based curriculum addressed proper sizing and use of cuffed endotracheal tubes, care of the intubated child and perioperative considerations of the surgical airway patient. Providers completed pre and post-curriculum quizzes to measure knowledge acquisition. Results Over 6-months, 281 patients were intubated. Sixty-three percent had improperly sized ETTs. Thirty-one percent had a failed or accidental extubation. All-cause mortality was 24%. One hundred and fifty-nine Salvadorian providers completed a learning behavior survey informing a video-based curriculum. Sixty-four providers completed the curriculum. Post-curriculum quiz scores increased by 18.7%. Surgeons, anesthesiologist, intensivists and speech pathologists demonstrated significant improvement (p Conclusion Nearly two-thirds of intubated patients in a PICU in El Salvador have improperly sized ETTs and one-third require reintubation following planned or accidental extubation. The development of this first of its kind video-based curriculum for critical care and surgical training regarding how to properly care for the intubated child is coupled with the development of a longitudinal database to record pediatric airway related morbidity and mortality in the largest pediatric hospital in El Salvador. This model and system can be used to track the reduction in airway related morbidity and mortality directly related to a systems based intervention both in El Salvador and then elsewhere.

Importance Health care organizations are complex and evolving systems. To date, longitudinal evaluation to ensure the sustainability of quality improvement (QI) initiatives has been missing from the otolaryngology literature. We sought to reassess perioperative management of laryngotracheal reconstruction, which requires adequate sedation. Objective Using principles of continuous QI, the objectives of this study were to (1) describe step-by-step methods to sustain QI efforts and (2) revisit a series of process, outcome, and balance measures for sedation weaning management following implementation of a new electronic health record (EHR). Design, Setting, and Participants A standardized sedation weaning protocol was previously developed and instituted in February 2013. To address healthcare system-wide changes, a 7-step, Institute for Healthcare Improvement methodology was used to reevaluate a series of measures comparing a previous postweaning group (2013-2014; 13 patients) and current post-EHR group (2016; 11 patients). We conducted a focus group review of these 24 patients. Main Outcomes and Measures The primary outcome measure was length of sedation weaning. Secondary outcome, process, and balance measures included total length of sedation, absence of standardized wean document, absence of specific recommendations on weaning regimen, length of stay, continued weaning at discharge, discharge location, absence of discharge instructions on weaning regimen or iatrogenic withdrawal syndrome (IWS), discharge within 72 hours of stopping weaning, and readmission. Results The postweaning and post-EHR groups were similar in age (20.5 months [95% CI, 11.92-29.15] vs 26.5 months [95% CI, 17.68-35.40]), as well as male sex (11 of 13 [85%] vs 10 of 11 [91%]), respectively. In the post-EHR group, the standardized sedation wean document was missing from 9 of 11 (82%) medical records. However, the primary outcome measure, length of sedation weaning, remained stable at 9.45 (95% CI, 7.62-11.29) days in the post-EHR group compared with 9.08 (95% CI, 7.00-11.18) days in the postweaning group. In addition, only 5 of 11 (46%) of discharges in the post-EHR group had specific guidance on weaning since the standardized template was no longer in use. As a result, in the post-EHR group, patients were 15.2 (95% CI, 0.46-242.34) times as likely to lack discharge instructions on weaning or IWS. Conclusions and Relevance Quality improvement is meant to be a continuous process in which reevaluation of care practices are regularly performed. System-wide redesign can be achieved using a formal methodological approach. Moving forward, notable QI opportunities for our institution included the development of a flexible sedation weaning template, as well as enhancements to discharge instructions to include IWS diagnosis and treatment.

Although there has been tremendous progress in quality improvement (QI) education for students and trainees in recent years, much less has been published regarding the training of active clinicians in QI. The Partners Clinical Process Improvement Leadership Program (CPIP) is a 6-day experiential program. Interdisciplinary teams complete a QI project framed by didactic sessions, interactive exercises, case-based problem sessions, and a final presentation. A total of 239 teams composed of 516 individuals have graduated CPIP. On completion, participant satisfaction scores average 4.52 (scale 1-5) and self-reported understanding of QI concepts improved. At 6 months after graduation, 66% of survey respondents reported sustained QI activity. Three opportunities to improve the program have been identified: (1) increasing faculty participation through online and tiered course offerings, (2) integrating the faculty-focused program with the trainee curriculum, and (3) developing a postgraduate curriculum to address the challenges of sustained improvement.

Safety assessment codes (SACs) are one method to evaluate adverse events and determine the need for a root cause analysis. Few facilities currently use SACs, and there is no literature examining their interrater reliability. Two independent raters assigned frequency, actual harm, and potential harm ratings to a sample of patient safety reports. An actual and potential SAC were determined. Percent agreement and Cohen's κ were calculated. Substantial agreement existed for the actual SAC (κ = 0.626, P.001), fair agreement for the potential SAC (κ = 0.266, P.001), and low agreement for potential harm (κ = 0.171, P = .002). Although there is subjectivity in all aspects of assigning SACs, the greatest is in potential severity. This presents a problem when using the potential SAC and is in agreement with previous literature showing significant subjectivity in determining potential harm. An operational framework is needed to strengthen reliability.

A recent case of conjoined twins required multiple hospitalizations in the pediatric intensive care unit and led to a difficult situation confronting staff regarding the potential separation where surgery would result in the death of one twin. The hospital ethics committee was consulted. A systematic approach was utilized to examine medical standards, historical precedents, and various ethical and legal frameworks. The ethics committee believed that either proceeding with or forgoing attempted separation surgery would be ethically acceptable. We share our reasoning and lessons learned for others facing this situation in the future.

INTRODUCTION The Partners Clinical Process Improvement Leadership Program provides quality improvement training for clinicians and administrators, utilizing graduates as volunteer peer coaches for mentorship. We sought to understand the factors associated with volunteer coach participation and gain insight into how to improve and sustain this program. METHODS Review of coach characteristics from course database and survey of frequent coaches. RESULTS Out of 516 Partners Clinical Process Improvement Leadership Program graduates from March 2010 to June 2015, 117 (23%) individuals volunteered as coaches. Sixty-one (52%) individuals coached once, 31 (27%) coached twice, and 25 (21%) coached 3 or more times. There were statistically significant associations between coaching and occupation (P = .005), Partners Clinical Process Improvement Leadership Program course taken (P = .001), and course location (P = .007). Administrators were more likely to coach than physicians (odds ratio: 1.75, P = .04). Reasons for volunteering as a coach included further development of skills, desire to stay involved with program, and enjoying mentoring. Reasons for repeated coaching included maintaining quality improvement skills, expanding skills to a wider variety of projects, and networking. CONCLUSIONS A peer graduate volunteer coach model is a viable strategy for interprofessional quality improvement mentorship. Strategies that support repeat coaching and engage clinicians should be promoted to ensure an experienced and diversified group of coaches.

BACKGROUND AND OBJECTIVES: There are limited data guiding vancomycin dosing practices in the pediatric population to target the goal troughs recommended by national vancomycin guidelines. In this study, we sought to improve adherence to guideline trough targets through a quality improvement intervention. METHODS: A retrospective analysis was first conducted to assess baseline performance. A multidisciplinary team then developed and implemented a standardized dosing algorithm recommending 15 mg/kg per dose for mild and moderate infections (goal trough: 10–15 µg/mL) and 20 mg/kg per dose for severe infections (goal trough: 15–20 µg/mL), both delivered every 6 hours (maximum single dose: 750 mg). The impact of the intervention was evaluated prospectively using standard statistics and quality improvement methodology. The outcome measures included the percentage of patients with an initial therapeutic trough and the time to therapeutic trough. RESULTS: A total of 116 patients (49 preintervention, 67 postintervention) were included. Postintervention, there was a significant increase in the percentage of patients with an initial therapeutic trough (6.1% to 20.9%, P = .03) and in the percentage of patients with initial troughs between 10 and 20 µg/mL (8.2% to 40.3%, P < .001). The time to therapeutic trough decreased from 2.78 to 1.56 days (P = .001), with the process control chart showing improved control postintervention. Vancomycin-related toxicity was unchanged by the intervention (6.1% versus 4.5%; P = .70). CONCLUSIONS: Using quality improvement methodology with standardized higher initial vancomycin doses, we demonstrated improved adherence to national trough guidelines without noted safety detriment.

Junctional epidermolysis bullosa (JEB), generalized severe (previously called JEB, Herlitz-type) has an extremely poor prognosis, with a mean age of death at 5 months old and most dead before age 3 years. We describe a typical case of a neonate with JEB who developed failure to thrive before his death from fungal septicemia at 4 months of age. This case highlights the ethical considerations of invasive treatments such as gastrostomy tube placements, intubations, and central line placements in neonates with JEB. We review the literature as well as discuss the ethical conundrums in the care of patients with JEB and other severe forms of epidermolysis bullosa.

Background: Use of dexmedetomidine in pediatric critical care is common, despite lack of prospective studies on its hemodynamic effects. Objective: To describe cardiovascular effects in critically ill children treated with a constant continuous infusion of dexmedetomidine without a loading dose at highest Food and Drug Administration-approved adult dose. Methods: Prospective, pilot study of 17 patients with dexmedetomidine infused at a rate of 0.7 μg/kg/h for 6 to 24 hours. Heart rate (HR) and blood pressure (BP) values over time were analyzed by a random effects mixed model. Results: Patients with median age of 1.6 years (1 month to 17 years) and median weight of 11.8 kg (2.8-84 kg) received an infusion for a mean of 16 ± 7.2 hours. There were no cardiac conduction abnormalities. One patient required discontinuation of infusion for predetermined low HR termination criteria at hour 13 of infusion; there was no clinical compromise and it coincided with planned extubation. Decreased HR of 20% from baseline was found in 35% of patients. The mean HR reduction was largest at hour 13 of infusion with a decrease of 13 ± 17 bpm from baseline, but HR changes over time were not statistically significant. Blood pressure effects included a decrease in 12% and an increase in 29%. There was a small but statistically significant increase in systolic BP of 0.4 mm Hg/h of infusion, P < .001. Conclusion: A continuous infusion of 0.7 μg/kg/h of dexmedetomidine without a loading dose for up to 24 hours in critically ill children had tolerable effects on HR and BP.