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Introduction: Death certification is a health indicator and a public health surveillance tool. High-quality death certificate ensures reliability of mortality statistics used to direct the arranging of health-related programs and leading assessments of research and proper healthcare outcomes. The World Health Organization (WHO) puts Egypt in the group of 'low quality' death registration data. The aim of this study was to evaluate the impact of composite training and audit intervention on accurate completion of death notification forms (DNFs) in Assiut University Children Hospital (AUCH) that has an average monthly mortality of 120 children's deaths., Methods: A Quasi-experimental study design was conducted among residents of AUCH. The intervention consisted of 1- Preparing training material with basic information on how to report causes of death according to WHO criteria and case scenarios extracted from the medical records of children who died at AUCH, 2- One hundred residents of the AUCH were trained in one day workshops in 4 groups, with a pre-post knowledge assessment questionnaire. 3- A weekly audit of a sample of 10-15 DNFs was done for six months with reporting of findings to quality assurance director of the hospital., Results: Eighty- nine physicians completed the pre-post knowledge assessment with significant increase in knowledge score after the intervention (15.7 ± 3.2 vs. 11.9 ± 2.8). There was a significant decrease in the errors of reporting on the DNFs. The main improvement was in decrease from 90 to 18% in reporting the mechanism of death, and significant decline in writing cause of death in Arabic language only., Conclusion: Accurate reporting of the medical cause of death can be achieved by educational intervention targeting physicians with institutionalizing of audit system for continuous quality improvement., Competing Interests: Declarations. Ethics approval and consent to participate: The current study was conducted following approval from the Institutional Review Board (IRB) of the Faculty of Medicine, Assiut university (IRB No. 04-2023-300340). Administrative approval was obtained from the head of Assiut University children hospital before conducting the study. Participation was voluntary with confidentiality and privacy of all data was assured. Several measures were taken to ensure the protection of privacy during both data collection and analysis. Informed consent was obtained from all resident physicians, clearly outlining our commitment to protecting their privacy. The objective of the training was explained by administering the pretest to the participants to obtain their informed consent. Data was analyzed anonymously where identifiers were removed and during data collection, all data was securely entered in a separate excel sheet, with access limited to authorized research personnel only. Mortality data was handled with particular care: it was isolated from other data and entered in a separate excel sheet, and all analyses were conducted in a secure environment. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Infants admitted to NICUs in children's hospitals represent a different population than those in a traditional birth hospital. The patients in a children's hospital NICU often have the most complex neonatal diagnoses and are cared for by various subspecialists. The Children's Hospitals Neonatal Consortium is a collaborative of more than 40 NICUs that collect data and perform quality improvement (QI) work across the United States and Canada. The collaborative's database provides an opportunity to benchmark clinical outcomes for this specialized population and to support the QI efforts. In this review, we summarize the success of individual collaborative QI projects focused on improving the care of the neonate in the perioperative period related to clinical team handoffs, postoperative hypothermia prevention, and improvement of postoperative pain management. The collaborative's experience can serve as a model for other national collaboratives seeking to support QI efforts., (Copyright © 2024 by the American Academy of Pediatrics.)

Introduction: The American College of Surgeons Children's Surgery Verification (CSV) status recognizes hospitals that deliver high-quality pediatric surgical care. Texas has 5 CSV centers in three cities, which may limit equitable access to care. We explored the characteristics and outcomes of infants admitted in Texas as a function of facility CSV status., Materials and Methods: We retrospectively reviewed a state-wide hospital discharge database (2013-2021). All patients <1 y of age were included. Patients transferred to an outside hospital were excluded to avoid double counting. Descriptive statistics and chi-square analysis were performed., Results: We analyzed 3,617,173 admissions, with 211,278 (6%) treated at CSV centers. CSV admissions were less likely to be inborn (46% versus 93%) and more likely to be transfers (16% versus 1%). CSV centers also had sicker patients (32% versus 13% extreme illness severity) with higher mortality rates (1% versus 0%), longer length of stay (9 ± 22 versus 4 ± 9), and higher operative rates (33% versus 20%). However, mortality was lower at CSV centers when matched for illness severity. Proportionately more patients from rural counties (9% versus 4%) and counties along the United States-Mexico border (13% versus 1%), as well as patients of Hispanic ethnicity (39% versus 33%), were treated at non-CSV centers. Meanwhile, proportionately more African Americans (21% versus 11%) were treated at CSV centers., Conclusions: CSV centers are associated with improved outcomes among patients with high illness severity. Population differences among patients treated at CSV centers compared to non-CSV centers may represent disparities in access to care and warrant further evaluation., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Our goal was to understand the general attitudes of pediatric urologists regarding the U.S. News & World Report rankings for Best Children's Hospitals in Urology., Materials and Methods: We performed a cross-sectional survey study distributed via email to active and candidate members of the Societies for Pediatric Urology from October 2022 to December 2022. This anonymous survey was iteratively developed to contain multiple choice questions gathering information on demographics, personal interaction with the rankings system, and about attitudes toward the rankings across various domains., Results: Of the 515 members surveyed, 264 pediatric urologists responded to the survey for a response rate of 51%. There was representation from all sections of the AUA and across all age categories and practice models. Overall, of the respondents, 71% disagreed that the rankings had led to improvements in care and 75% disagreed that programs were reporting their data honestly. Additionally, 71% believed the rankings are inaccurate in reflecting patient outcomes. The majority (86%) of respondents stated they would support organized efforts to withdraw from the rankings. This was significantly different by ranking cohort, with 78% from top 10 programs endorsing withdrawal vs 89% from those programs not in the top 10., Conclusions: Our survey found that most pediatric urologists would support efforts to withdraw from participating in the rankings and believe that programs are dishonest in reporting their data. The majority also do not believe a survey can adequately distinguish between programs. This highlights a clear need for a critical reevaluation of the rankings.

There are well-documented inequities in the quality of care and health outcomes of minoritized youth. Patient safety and quality improvement (QI) work with an equity focus has been identified as an important strategy to remedy these existing inequities. In this article, we will present evidence of inequities in pediatric hospital-based care, describe root causes with a focus on structural racism, highlight existing frameworks for applying equity principles to patient safety and QI, and provide best practices and recommendations on evaluating patient safety and QI data towards advancing equity in pediatric hospital-based care., Competing Interests: Declaration of Competing Interest None for all authors., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Aims: The potential harm associated with medication errors is widely reported, but data on actual harm are limited. When actual harm has been measured, assessment processes are often poorly described, limiting their ability to be reproduced by other studies. Our aim was to design and implement a new process to assess actual harm resulting from medication errors in paediatric inpatient care., Methods: Prescribing errors were identified through retrospective medical record reviews (n = 26 369 orders) and medication administration errors through direct observation (n = 5137 administrations) in a tertiary paediatric hospital. All errors were assigned potential harm severity ratings on a 5-point scale. Multidisciplinary panels reviewed case studies for patients assigned the highest three potential severity ratings and determined the following: actual harm occurrence and severity level, plausibility of a link between the error(s) and identified harm(s) and a confidence rating if no harm had occurred., Results: Multidisciplinary harm panels (n = 28) reviewed 566 case studies (173 prescribing related and 393 administration related) and found evidence of actual harm in 89 (prescribing = 22, administration = 67). Eight cases of serious harm cases were found (prescribing = 1, administration = 7) and no cases of severe harm. The panels were very confident in 65% of cases (n = 302) where no harm was found. Potential and actual harm ratings varied., Conclusions: This harm assessment process provides a systematic method for determining actual harm from medication errors. The multidisciplinary nature of the panels was critical in evaluating specific clinical, therapeutic and contextual considerations including care delivery pathways, therapeutic dose ranges and drug-drug and drug-disease interactions., (© 2024 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

Background: Hospital-acquired urinary tract infections (UTIs) have a detrimental effect on patients, families, and hospital resources. The Sydney Children's Hospital Network (SCHN) participates in the NSQIP-Pediatric (NSQIP-P) to monitor postoperative complications. NSQIP-P data revealed that the median UTI rate at SCHN was 1.75% in 2019, 3.5 times higher than the NSQIP-P target rate of 0.5%. Over three quarters of the NSQIP-P identified patients with UTI also had a urinary catheterization performed intraoperatively. A quality improvement project was conducted between mid-2018 and 2021 to minimize catheter-associated UTIs (CAUTIs) at SCHN., Study Design: NSQIP-P samples include pediatric (younger than 18 years) surgical patients from an 8-day cycle operative log. NSQIP-P data are statistically analyzed by the American College of Surgeons and provide biannual internationally benchmarked reports. The project used clinical redesign methodology with a 6-phase process for quality improvement projects., Results: The objectives of the project were to reduce urinary catheter duration of use, educate parents or carers, and improve catheter care and insertion technique by health staff. The duration of a urinary catheter in situ reduced from a median of 4.5 to 3 days from 2017 to 2021. The median NSQIP-P UTI rate at SCHN was reduced by 47.4% from 1.75% in 2019 to 0.9% in 2022., Conclusions: A multifactorial approach in quality improvement has been shown to be an effective strategy to reduce UTI rates at SCHN, and patient outcomes were improved within a 3-year timeframe. Although this project has reduced UTI rates at SCHN, there remain opportunities for further improvement., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Structured emergency room concepts have been shown to contribute to patient safety. Until now there has been no uniform emergency room concept for critically ill and seriously injured children and adolescents in the emergency room at the Altona Children's Hospital in Hamburg. This concept has been newly developed in interdisciplinary cooperation and includes the use of new clinical premises as well as new responsibilities and team compositions. The introduction of new processes and rooms for handling emergencies is associated with a risk of overlooking latent safety deficiencies or detecting them only after the process has been implemented. This may have a direct impact on patient safety. Before moving to new clinical premises, in situ simulation can be helpful to identify and to resolve latent safety threats in advance. Therefore, this method was chosen to test the newly created emergency room concept in the future emergency room at the Altona Children's Hospital., Methods: Two in situ simulations were carried out in the future real emergency room. Latent safety threats detected by the observation team and the participants (medical and nursing staff of the Altona Children's Hospital from the departments of pediatric surgery, traumatology, orthopedics, pediatrics, anesthesia, intensive care medicine, radiology, emergency medicine) were collected using free text notes after the simulations and evaluated retrospectively. In order to better deal with these latent safety threats, the observations were classified into different categories: working environment (e.g., lack of equipment, unfavorable positioning of material), process (e.g., lack of defined responsibilities in the team) and other safety threats that did not fall into one of the two categories defined., Results: A total of 51 latent safety threats were identified during the two in situ simulations. Of these, 22 (43.1%) were assigned to the "working environment" category, 20 (39.2%) to the "process" category and 9 (17.7%) to the "other safety threats" category. Of the latent safety threats identified, 46 (90.2 %) could be resolved before the emergency room was put into operation. For the non-recoverable safety threats, safety concepts were developed in order to further minimize the risk of patient hazard., Discussion: With the help of this study, it could be shown that the implementation of in situ simulation before the commissioning of new clinical premises and the introduction of new processes can contribute to the detection of latent safety threats in an interdisciplinary German pediatric emergency department., (Copyright © 2023. Published by Elsevier GmbH.)

Background and Objectives: Quality improvement (QI) has the potential to reduce health disparities through multiple mechanisms, including by standardizing care and addressing social barriers to health. National organizations require that hospital systems integrate equity into quality efforts, but effective approaches remain unclear. We aimed to examine the association of hospital-based pediatric QI interventions and racial and ethnic, language, and socioeconomic disparities in health outcomes., Methods: Quantitative studies from January 1, 2000 to December 11, 2023 reporting the effects of pediatric hospital-based QI were selected from PubMed and Embase. Studies were excluded if outcomes were not stratified by race and ethnicity, language, or socioeconomic status. Studies were reviewed in duplicate for inclusion and by 1 author for data extraction., Results: A total of 22 studies were included. Most studies (n = 19, 86%) revealed preexisting disparities, and 68% of those (n = 13) found disparities reductions post-intervention. Studies with disparity-focused objectives or interventions more commonly found reduced disparities than studies of general QI (85% vs 33%). Hospital-based process standardization was associated with reduced disparities in provider practices. Most interventions associated with reduced disparities in patient-facing outcomes involved community/ambulatory partnership. Limitations included potential exclusion of relevant studies, topic heterogenity, and risk of bias., Conclusions: Although the authors of few published hospital-based QI initiatives assessed their equity effect, intentionally designed QI studies were associated with reduced disparities. Interventions focused on care standardization may reduce disparities in care quality, although multilevel interventions are likely needed to affect the health care structures that influence more significant patient outcomes., (Copyright © 2024 by the American Academy of Pediatrics.)

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

Objectives: The objective of this article is twofold. First, to present a comprehensive internal assessment of the hospital by different groups of stakeholders and, second, to determine whether there are common needs and wishes that, if incorporated in the hospital vision, will enable future development., Background: The Children's Memorial Health Center is the largest children's hospital in Poland. The hospital began operations in 1977 with a vision to be a modern healthcare facility that provides comprehensive care for children. That vision has not changed over time but everything else did., Methods: Six design thinking sessions were conducted with 83 employees and 40 respondents who used health services in the hospital in the past, along with in-depth interviews with 25 representatives of management to gather data for the hospital assessment., Results: Sixty-three features influencing future development were identified. Seven groups of features were classified to be either transformation drivers (four groups) or enablers (three groups). We focused on features that were indicated by all groups of respondents to define a common vision for future development., Conclusions: Depending on the respondent's role in the healthcare ecosystem, the list of variables within each of seven groups defining the "hospital of the future" was different while evaluating the healthcare services. Therefore, all stakeholders must be engaged in the ideation process to create a strategy for a future care model driven by innovation.

Background and Objectives: Viral respiratory infections are common in children, and practice guidelines do not recommend routine testing for typical viral illnesses. Despite results often not impacting care, nasopharyngeal swabs for viral testing are frequently performed and are an uncomfortable procedure. The aim of this initiative was to decrease unnecessary respiratory viral testing (RVT) in the emergency department (ED) and the pediatric medicine wards (PMWs) by 50% and 25%, respectively, over 36 months., Methods: An expert panel reviewed published guidelines and appropriate evidence to formulate an RVT pathway using plan-do-study-act cycles. A multifaceted improvement strategy was developed that included implementing 2 newer, more effective tests when testing was deemed necessary; electronic order modifications with force functions; audit and feedback; and education. By using statistical process control charts, the outcomes analyzed were the percentage of RVT ordered in the ED and the rate of RVT ordered on the PMWs. Balancing measures included return visits leading to admission and inpatient viral nosocomial outbreaks., Results: The RVT rate decreased from a mean of 3.0% to 0.5% of ED visits and from 44.3 to 30.1 per 1000 patient days on the PMWs and was sustained throughout the study. Even when accounting for the new rapid influenza test available in the ED, a 50% decrease in overall ED RVT was still achieved without any significant impact on return visits leading to admission or inpatient nosocomial infections., Conclusions: Through implementation of a standardized, electronically integrated RVT pathway, a decrease in unnecessary RVT was successfully achieved. Audit and feedback, reminders, and biannual education all supported long-term sustainability of this initiative., Competing Interests: FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: Emergency department visits for anaphylaxis have increased considerably over the past few decades, especially among children. Despite this, anaphylaxis management remains highly variable and contributes to significant health care spending. On the basis of emerging evidence, in this quality improvement project we aimed to safely decrease hospitalization rates, increase the use of cetirizine, and decrease use of corticosteroids for children with anaphylaxis by December 31, 2019., Methods: A multipronged intervention strategy including a revised evidence-based guideline was implemented at a tertiary children's teaching hospital by using the Model for Improvement. Statistical process control was used to evaluate for changes in key measures. Length of stay and unplanned return visits within 72 hours were monitored as process and balancing measures, respectively. As a national comparison, hospitalization rates were compared with other hospitals' data from the Pediatric Health Information System., Results: Hospitalizations decreased significantly from 28.5% to 11.2% from preimplementation to implementation, and the balancing measure of 72-hour revisits was stable. The proportion of patients receiving cetirizine increased significantly from 4.2% to 59.7% and use of corticosteroids decreased significantly from 72.6% to 32.4% in patients without asthma. The proportion of patients meeting length of stay criteria increased from 53.3% to 59.9%. Hospitalization rates decreased nationally over time., Conclusions: We reduced hospitalizations for anaphylaxis by 17.3% without concomitant increases in revisits, demonstrating that unnecessary hospitalizations can be safely avoided. The use of a local evidence-based guideline paired with close outcome monitoring and sustained messaging and feedback to clinicians can effectively improve anaphylaxis management., Competing Interests: FINANCIAL DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: Transportation influences attendance at posthospitalization appointments (PHAs). In 2017, our pediatric hospital medicine group found that our patients missed 38% of their scheduled PHAs, with several being due to transportation insecurity. To address this, we implemented a quality improvement project to perform inpatient assessment of transportation insecurity and provide mitigation with the goal of improving attendance at PHAs., Methods: The process measure was the percentage of patients with completed transportation insecurity screening, and the outcome measure was PHA attendance. An interprofessional team performed plan-do-study-act cycles. These included educating staff about the significance of transportation insecurity, its assessment, and documentation; embedding a list of local transportation resources in discharge instructions and coaching families on using these resources; notifying primary care providers of families with transportation insecurity; and auditing PHA attendance., Results: Between July 2018 and December 2019, electronic health record documentation of transportation insecurity assessment among patients on the pediatric hospital medicine service and discharged from the hospital (n = 1731) increased from 1% to 94%, families identified with transportation insecurity increased from 1.2% to 5%, and attendance at PHAs improved for all patients (62%-81%) and for those with transportation insecurity (0%-57%). Our balance measure, proportion of discharges by 2 pm, remained steady at 53%. Plan-do-study-act cycles revealed that emphasizing PHA importance, educating staff about transportation insecurity, and helping families identify and learn to use transportation resources all contributed to improvement., Conclusions: Interventions implemented during the inpatient stay to assess for and mitigate transportation insecurity led to improvement in pediatric PHA attendance., Competing Interests: FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Background and Objectives: Sudden unexpected infant death often results from unsafe sleep environments and is the leading cause of postneonatal mortality in the United States. Standardization of infant sleep environment education has been revealed to impact such deaths. This standardized approach is similar to safety prevention bundles typically used to monitor and improve health outcomes, such as those related to hospital-acquired conditions (HACs). We sought to use the HAC model to measure and improve adherence to safe sleep guidelines in an entire children's hospital., Methods: A hospital-wide safe sleep bundle was implemented on September 15, 2017. A safe sleep performance improvement team met monthly to review data and discuss ideas for improvement through the use of iterative plan-do-study-act cycles. Audits were performed monthly from March 2017 to October 2019 and monitored safe sleep parameters. Adherence was measured and reviewed through the use of statistical process control charts (p-charts)., Results: Overall compliance improved from 9% to 72%. Head of bed flat increased from 62% to 93%, sleep space free of extra items increased from 52% to 81%, and caregiver education completed increased from 10% to 84%. The centerline for infant in supine position remained stable at 81%., Conclusions: Using an HAC bundle safety prevention model to improve adherence to infant safe sleep guidelines is a feasible and effective method to improve the sleep environment for infants in all areas of a children's hospital., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Recent advances in immunology, genomics, and cellular therapy have opened numerous therapeutic possibilities in pediatric hematology-oncology, generating new hope in poor prognosis situations. How decisions are made when it comes to treatments and aims needs to be explored in this new technologic context. In particular, their impact on the gold standard of early referral to palliative care must be assessed., Materials and Methods: Stemming from an ethnographic study combining semistructured interviews and observations carried out in a hematopoietic stem cell transplant unit in a Montréal Pediatric Hospital, we discuss the decision-making process when a patient faces poor prognosis., Results and Discussion: Although health care providers individually envisioned that palliative care may be the best course of action for patients receiving emergent therapy, they remained collectively in the curative mode. The intricate relationship between science, hope, caregiver, and care receiver sustains this perspective even when (near) death is the probable outcome. When proven treatment fails, emerging therapeutic possibilities offer new hope that can delay the referral to the palliative care team., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

As North American hospitals serve increasingly diverse patient populations, including recent immigrants, refugees, and returned travelers, all pediatric hospitalists (PHs) require foundational competency in global health, and a subset of PHs are carving out niches focused in global health. Pediatric hospitalists are uniquely positioned to collaborate with low- and middle-income country clinicians and child health advocates to improve the health of hospitalized children worldwide. Using the 2018 WHO standards for improving the quality of care for children and adolescents worldwide, we describe how PHs' skills align closely with what the WHO and others have identified as essential elements to bring high-quality, sustainable care to children in low- and middle-income countries. Furthermore, North American global health hospitalists bring home expertise that reciprocally benefits their home institutions.

Most children in hospital who are clinically deteriorating are monitored regularly, and their treatment is escalated effectively. However a small, but significant, number of deteriorating children experience suboptimal outcomes because of a failure to recognise and respond to acute deterioration early enough leading to unintended harm. Tragically this occasionally can have fatal consequences. Investigations into these rare events highlight common themes of missed early signs of deterioration in children, prompting regulatory agencies to suggest paediatric early warning systems (PEWS) to aid clinical practice. In England, track and trigger tools (TTT), which are one facet of PEWS have been widely rolled out but in a heterogeneous fashion. The evidence for TTT is mixed but they are complex interventions and current outcomes do not fully define the entirety of their potential impact. This article explains the rationale behind the decision of the NHS England and NHS Improvement, Royal College of Paediatrics and Child Health and Royal College of Nursing to implement a standardised inpatient PEWS as part of a system-wide paediatric observations tracking system in England and how this fits into a wider programme of activity., Competing Interests: Competing interests: Authors are all members of the National SPOT delivery board., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Pediatric behavioral health admissions to children's hospitals for disposition planning are steadily increasing. These children may exhibit violent behaviors, which can escalate to application of physical limb restraints for safety. Using quality improvement methodology, we sought to decrease physical restraint use on children admitted to our children's hospital for behavioral health conditions from a baseline mean of 2.6% of behavioral health patient days to <1%., Methods: We included all children ≥3 years of age admitted to our hospital medicine service with a primary behavioral health diagnosis from July 1, 2016, to February 1, 2020. A multidisciplinary team, formed in July 2018, tested interventions based on key drivers targeted toward our aim. The primary outcome measure was the percent of behavioral health patient days on which physical restraints were ordered. The balancing measure was the percent of patient days with a staff injury event. Statistical process control charts were used to view and analyze data., Results: Our cohort included 3962 consecutive behavioral health patient encounters, encompassing a total of 9758 patient days. A 2-year baseline revealed physical restraint orders placed on 2.6% of behavioral health patient days, which was decreased to 0.9% after interventions and has been sustained over 19 months without any change in staff injuries., Conclusions: Team-based quality improvement methodology was associated with a sustained reduction in physical restraint use on children admitted for behavioral health conditions to our children's hospital. These results indicate that physical restraint use can be safely reduced in children's hospitals., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives/hypothesis: To produce a sustained reduction in opioid prescriptions in patients <5 years of age undergoing T&A through utilization of standardized algorithms and electronic health record (EHR) automation tools., Study Design: Prospective quality improvement initiative., Methods: Plan-do-study-act (PDSA) methodology was used to design an age-based postoperative pain regimen in which children <5 years of age received a non-opioid pain regimen, and option to prescribe oxycodone for additional pain relief was given for children >5 years of age. Standardized discharge instructions and automated, age-specific order sets were created to facilitate adherence. Rate of discharge opioid prescription was monitored and balanced against post-discharge opioid prescriptions and returns to the emergency department (ED)., Results: In children <5 years of age undergoing T&A, reduction in opioid prescription rates from 65.9% to 30.9% after initial implementation of the order set was noted. Ultimately, reduction of opioid prescribing rates to 3.7% of patients was noted after pain-regimen consensus and EHR order set implementation. Opioid prescriptions in patients >5 years of age decreased from 90.6% to 58.1% initially, and then down 35.9% by the last time point analyzed. Requests for outpatient opioid prescriptions did not increase. There was no significant change in returns to the emergency ED for pain management, or in the number opioids prescribed when patients returned to the ED., Conclusions: Iterative cycles of improvement utilizing standardized pain management algorithms and EHR tools were effective means of producing a sustained reduction in opioid prescriptions in postoperative T&A patients. Such findings suggest a framework for similar interventions in other pediatric otolaryngology settings., Level of Evidence: 4 Laryngoscope, 131:E2337-E2343, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Background and Objectives: Laboratory testing is performed frequently in the NICU. Unnecessary tests can result in increased costs, blood loss, and pain, which can increase the risk of long-term growth and neurodevelopmental impairment. Our aim was to decrease routine screening laboratory testing in all infants admitted to our NICU by 20% over a 24-month period., Methods: We designed and implemented a multifaceted quality improvement project using the Institute for Healthcare Improvement's Model for Improvement. Baseline data were reviewed and analyzed to prioritize order of interventions. The primary outcome measure was number of laboratory tests performed per 1000 patient days. Secondary outcome measures included number of blood glucose and serum bilirubin tests per 1000 patient days, blood volume removed per 1000 patient days, and cost. Extreme laboratory values were tracked and reviewed as balancing measures. Statistical process control charts were used to track measures over time., Results: Over a 24-month period, we achieved a 26.8% decrease in laboratory tests performed per 1000 patient days (∽51 000 fewer tests). We observed significant decreases in all secondary measures, including a decrease of almost 8 L of blood drawn and a savings of $258 000. No extreme laboratory values were deemed attributable to the interventions. Improvement was sustained for an additional 7 months., Conclusions: Targeted interventions, including guideline development, dashboard creation and distribution, electronic medical record optimization, and expansion of noninvasive and point-of-care testing resulted in a significant and sustained reduction in laboratory testing without notable adverse effects., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objective: To develop a diagnostic error index (DEI) aimed at providing a practical method to identify and measure serious diagnostic errors., Study Design: A quality improvement (QI) study at a quaternary pediatric medical center. Five well-defined domains identified cases of potential diagnostic errors. Identified cases underwent an adjudication process by a multidisciplinary QI team to determine if a diagnostic error occurred. Confirmed diagnostic errors were then aggregated on the DEI. The primary outcome measure was the number of monthly diagnostic errors., Results: From January 2017 through June 2019, 105 cases of diagnostic error were identified. Morbidity and mortality conferences, institutional root cause analyses, and an abdominal pain trigger tool were the most frequent domains for detecting diagnostic errors. Appendicitis, fractures, and nonaccidental trauma were the 3 most common diagnoses that were missed or had delayed identification., Conclusions: A QI initiative successfully created a pragmatic approach to identify and measure diagnostic errors by utilizing a DEI. The DEI established a framework to help guide future initiatives to reduce diagnostic errors., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The provision of health care in the perioperative setting has undergone significant changes due to severe respiratory distress syndrome coronavirus-2 (SARS-CoV-2). Hospital facilities have been tasked with developing and implementing personal protective equipment (PPE) protocols to protect both medical providers and patients. Texas Children's Hospital has created a set of protocols for donning and doffing PPE while managing surgical pediatric patients. These requirements have undergone numerous modifications as a result of our internal infrastructural recommendations and the Centers for Disease Control and Prevention guidance, which has led to more lenient regulations. While these perioperative PPE protocols were less stringent compared to the original guidelines, we were able to create a safe surgical environment without further exposing patients and health care providers to SARS-CoV-2. In this article, we detail the design, distribution, implementation, and modification of our institutional surgical PPE protocols., (© 2021 American Society for Healthcare Risk Management of the American Hospital Association.)

Objective: To cross-culturally adapt and validate the Montreal Children's Hospital Feeding Scale (MCH-FS) into Brazilian Portuguese., Methods: The MCH-FS, originally validated in Canada, was validated in Brazil as Escala Brasileira de Alimentação Infantil (EBAI) and developed according to the following steps: translation, production of the Brazilian Portuguese version, testing of the original and the Brazilian Portuguese versions, back-translation, analysis by experts and by the developer of the original questionnaire, and application of the final version. The EBAI was applied to 242 parents/caregivers responsible for feeding children from 6 months to 6 years and 11 months of age between February and May 2018, with 174 subjects in the control group and 68 ones in the case group. The psychometric properties evaluated were validity and reliability., Results: In the case group, 79% of children were reported to have feeding difficulties, against 13% in the control group. The EBAI had good internal consistency (Cronbach's alpha=0.79). Using the suggested cutoff point of 45, the raw score discriminated between cases and controls with a sensitivity of 79.4% and specificity of 86.8% (area under the ROC curve=0.87)., Conclusions: The results obtained in the validation process of the EBAI demonstrate that the questionnaire has adequate psychometric properties and, thus, can be used to identify feeding difficulties in Brazilian children from 6 months to 6 years and 11 months of age.

Objective: To describe the prevalence of neutralizing antibodies against poliovirus (PV1, PV2, and PV3) in blood samples of healthcare professionals aged 20 to 50 years., Methods: Health professionals who serve children at Darcy Vargas Children's Hospital and the Department of Pediatrics of Irmandade da Santa Casa de São Paulo. The sample size was calculated at 323 participants. The Mantel-Haenszel chi-square was used to verify differences between groups. The neutralization reaction detected human poliovirus antibodies. For susceptible individuals, vaccination with the inactivated+triple acellular polio vaccine was performed, and neutralizing antibodies were re-dosed after one week., Results: 333 professionals were studied - 92.8% were immune to poliovirus 1, 86.5% to poliovirus 2, and 63.3% to poliovirus 3; 37% had titers less than 1:8 for any serotype, 5;1% had titers below 1:8 for all three. Vaccination with inactivated polio vaccine was performed for susceptible participants, and neutralizing antibodies were dosed after one week, showing increased titers for all polioviruses., Conclusions: Despite the detection of a significant percentage of individuals with low poliovirus antibody titer, the challenge with vaccination demonstrated immune response compatible with poliovirus immunity.

Background: Pediatric musculoskeletal infection (MSKI) is a common cause of hospitalization with associated morbidity. To improve the care of pediatric MSKI, our objectives were to achieve 3 specific aims within 24 months of our quality improvement (QI) interventions: (1) 50% reduction in peripherally inserted central catheter (PICC) use, (2) 25% reduction in sedations per patient, and (3) 50% reduction in empirical vancomycin administration., Methods: We implemented 4 prospective QI interventions at our tertiary children's hospital: (1) provider education, (2) centralization of admission location, (3) coordination of radiology-orthopedic communication, and (4) implementation of an MSKI infection algorithm and order set. We included patients 6 months to 18 years of age with acute osteomyelitis, septic arthritis, or pyomyositis and excluded patients with complex chronic conditions or ICU admission. We used statistical process control charts to analyze outcomes over 2 general periods: baseline (January 2015-October 17, 2016) and implementation (October 18, 2016-April 2019)., Results: In total, 224 patients were included. The mean age was 6.1 years, and there were no substantive demographic or clinical differences between baseline and implementation groups. There was an 81% relative reduction in PICC use (centerline shift 54%-11%; 95% confidence interval 70-92) and 33% relative reduction in sedations per patient (centerline shift 1.8-1.2; 95% confidence interval 21-46). Empirical vancomycin use did not change (centerline 20%)., Conclusions: Our multidisciplinary MSKI QI interventions were associated with a significant decrease in the use of PICCs and sedations per patient but not empirical vancomycin administration., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives: To compare the performance and test characteristics of an automated sepsis screening tool with that of a manual sepsis screen in patients presenting to a pediatric emergency department (ED)., Methods: We conducted a retrospective cohort study of encounters in a pediatric ED over a 2-year period. The automated sepsis screening algorithm replaced the manual sepsis screen 1 year into the study. A positive case was defined as development of severe sepsis or septic shock within 24 hours of disposition from the ED. We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratios with 95% confidence intervals (CIs) for each., Results: There were 122 221 ED encounters during the study period and 273 cases of severe sepsis. During year 1 of the study, the manual screen was performed in 8910 of 61 026 (14.6%) encounters, resulting in the following test characteristics: sensitivity of 64.6% (95% CI 54.2%-74.1%), specificity of 91.1% (95% CI 90.5%-91.7%), PPV of 7.3% (95% CI 6.3%-8.5%), and NPV of 99.6% (95% CI 99.5%-99.7%). During year 2 of the study, the automated screen was performed in 100% of 61 195 encounters, resulting in the following test characteristics: sensitivity of 84.6% (95% CI 77.4%-90.2%), specificity of 95.1% (95% CI 94.9%-95.2%), PPV of 3.7% (95% CI 3.4%-4%), and NPV of 99.9% (95% CI 99.9%-100%)., Conclusions: An automated sepsis screening algorithm had higher sensitivity and specificity than a widely used manual sepsis screen and was performed on 100% of patients in the ED, ensuring continuous sepsis surveillance throughout the ED stay., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background and Objectives: The pediatric inpatient discharge medication process is complicated, and caregivers have difficulty managing instructions. Authors of few studies evaluate systematic processes for ensuring quality in these care transitions. We aimed to improve caregiver medication management and understanding of discharge medications by standardizing the discharge medication process., Methods: An interprofessional team at an urban, tertiary care children's hospital trialed interventions to improve caregiver medication management and understanding. These included mnemonics to aid in complete medication counseling, electronic medical record enhancements to standardize medication documentation and simplify dose rounding, and housestaff education. The primary outcome measure was the proportion of discharge medication-related failures in each 4-week period. Failure was defined as an incorrect response on ≥1 survey questions. Statistical process control was used to analyze improvement over time. Process measures related to medication documentation and dose rounding were compared by using the χ 2 test and process control., Results: Special cause variation occurred in the mean discharge medication-related failure rate, which decreased from 70.1% to 36.1% and was sustained. There were significantly more complete after-visit summaries (21.0% vs 85.1%; P < .001) and more patients with simplified dosing (75.2% vs 95.6%; P < .001) in the intervention period. Special cause variation also occurred for these measures., Conclusions: A systematic approach to standardizing the discharge medication process led to improved caregiver medication management and understanding after pediatric inpatient discharge. These changes could be adapted by other hospitals to enhance the quality of this care transition., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: The increasing use of antifungal drugs (AF) in children and the concern for related adverse events and costs has led to the development of specific AF stewardship programmes (AFS). Studies in adult patients have shown improvements in AF prescription and usage after implementation, but paediatric data are scant. The aim of this PROAFUNGI study was to describe the use and appropriateness of AF in a high complexity paediatric centre., Methods: Observational, prospective, single-centre, modified point-prevalence study (11 surveys, July-October 2018), including paediatric (< 18 years) patients receiving at least one systemic AF. Prescriptions were evaluated by the AFS team., Results: The study included 119 prescriptions in 55 patients (53% males, median age 8.7 years [IQR 2.4-13.8]). The main underlying condition was cancer (45.5% of patients; HSCT in 60% of them); and the first indication for AF was prophylaxis (75 prescriptions, 63.2%). Liposomal amphotericin B was used most commonly (46% prescriptions), mainly as prophylaxis (75%). Among the 219 evaluations, 195 (89%) were considered optimal. The reason for non-optimal prescriptions was mostly lack of indication (14/24), especially in critical patients with ventricular assist devices. The use of AF without paediatric approval accounted for 8/24 inappropriate prescriptions., Conclusions: A high rate of AF appropriateness was found for the children's hospital as a whole, in relation with a well-established AFS. Nonetheless, the identification of specific areas of improvement should guide future actions of the AFS team, which will focus mainly on prophylaxis in critically ill patients receiving circulatory assistance and the use of non-approved drugs in children.

Objectives: Bedside delivery of discharge medications improves caregiver understanding and experience. Less is known about its impact on medication adherence. We aimed to improve antimicrobial adherence by increasing on-time first home doses for patients discharged from the pediatric hospital medicine service from 33% to 80% over 1 year via creation of a discharge medication delivery and counseling "Meds to Beds" (M2B) program., Methods: Using sequential plan-do-study-act cycles, an interprofessional workgroup implemented M2B on select pediatric hospital medicine units at our quaternary children's hospital from October 2017 through December 2018. Scripted telephone surveys were conducted with caregivers of patients prescribed antimicrobial agents at discharge. The primary outcome measure was on-time administration of the first home antimicrobial dose, defined as a dose given within the time of the inpatient dose equivalent plus 25%. Process measures primarily assessed caregiver report of barriers to adherence. Run charts, statistical process control charts, and inferential statistics were used for data analysis., Results: Caregiver survey response rate was 35% (207 of 585). Median on-time first home antimicrobial doses increased from 33% to 67% ( P < .001). Forty percent of M2B prescriptions were adjusted before discharge because of financial or insurance barriers. M2B participants reported significantly less difficulty in obtaining medications compared with nonparticipants (1% vs 17%, P < .001)., Conclusions: The M2B program successfully increased parental report of timely administration of first home antimicrobial doses, a component of overall adherence. The program enabled providers to identify and resolve prescription problems before discharge. Importantly, caregivers reported reduced barriers to medication adherence., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: An estimated 10% of Americans experience a diagnostic error annually, yet little is known about pediatric diagnostic errors. Physician reporting is a promising method for identifying diagnostic errors. However, our pediatric hospital medicine (PHM) division had only 1 diagnostic-related safety report in the preceding 4 years. We aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months., Methods: Our improvement team used the Model for Improvement, targeting the PHM service. To promote a safe reporting culture, we used the term diagnostic learning opportunity (DLO) rather than diagnostic error, defined as a "potential opportunity to make a better or more timely diagnosis." We developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. The outcome measure, the number of DLO reports per 100 patient admissions, was tracked on an annotated control chart to assess the effect of our interventions over time. We evaluated DLOs using a formal 2-reviewer process., Results: Over the course of 13 weeks, there was an increase in the number of reports filed from 0 to 1.6 per 100 patient admissions, which met special cause variation, and was subsequently sustained. Most events (66%) were true diagnostic errors and were found to be multifactorial after formal review., Conclusions: We used quality improvement methodology, focusing on psychological safety, to increase physician reporting of DLOs. This growing data set has generated nuanced learnings that will guide future improvement work., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Appendicitis is a common indication for urgent abdominal surgery in the pediatric population. The postoperative management varies significantly in time to discharge and cost of care. The objective of this study was to investigate whether implementation of an evidence-based protocol after an appendectomy would lead to decreased length of stay and cost of care., Methods: In 2014 at the Children's Hospital of Pittsburgh, an initiative to develop an evidenced-based protocol to treat appendicitis was undertaken. A work group was formed of pediatric surgeons and other important personnel to determine best practices. Treatment pathways were created. Pathways differed with recommendation on postoperative antibiotic choice and duration, diet initiation, and discharge criteria. Data were prospectively gathered from all patients (ages 0-18 y) with acute appendicitis from January 2015 to December 2016. Primary outcomes were length of stay and cost of care. Secondary outcomes were surgical site infection, readmission rate, and duration of postoperative antibiotics., Results: Among the 1289 patients, 481 patients were in the preprotocol cohort and 808 patients were in the postprotocol cohort. 27% of patients had an intraoperative diagnosis of complicated appendicitis. There was a significantly shorter length of stay in the postprotocol cohort (P < 0.001). Median costs for the whole cohort decreased 0.6% and 24.6% for patients with complicated appendicitis after protocol initiation (P < 0.01)., Conclusions: This study has demonstrated that introduction of an evidence-based clinical care protocol for pediatric patients with appendicitis leads to shorter hospital stay and decreased hospital costs., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: This cross-sectional study looked at the impact of the SARS-CoV-2/COVID-19 pandemic on pediatric emergency department (PED) attendances and admissions (as a proxy for severity of illness) in the United States and United Kingdom., Methods: Data were extracted for children and adolescents, younger than 16 years, attending Royal Manchester Children's Hospital (RMCH, United Kingdom), and Yale New Haven Children's Hospital (YNHCH, United States). Attendances for weeks 1 to 20 of 2020 and 2019 were compared, and likelihood of admission was assessed via calculation of odds ratios, using week 13 (lockdown) as a cutoff., Results: Attendance numbers for each PED decreased in 2020 compared with 2019 (RMCH, 29.2%; YNHCH, 24.8%). Odds of admission were significantly higher after lockdown than in 2019-RMCH (odds ratio, 1.26; 95% confidence interval, 1.08-1.46) and YNHCH (odds ratio, 1.60; 95% confidence interval, 1.31-1.98)., Conclusions: Although the absolute numbers of children and adolescents attending the PED and being admitted decreased after lockdown, the acuity of illness of those attending appears to be higher.

Background: In Ireland, the paediatric emergency department (PED) is tasked with acute healthcare provision to children and adolescents under 16 years of age. The population > 15 years attending the PED remains undescribed., Aims: The objective of the study is to describe the presentations of patients > 15 years to the PED of a national tertiary academic paediatric hospital., Methods: A retrospective review of electronic records identifying all patients (> 15 years) who presented from January 2014 to December 2015. Patient demographics, presenting complaint, diagnosis, treatment and disposition were recorded., Results: A total of 71,082 patients attended during the study period; of whom, 426 (0.6%) patients were aged 16 to 61 years. Over half were identified as having clearly defined chronic complex conditions. Three hundred and forty-five (89%) patients were known to the hospital paediatric services and under the care of specialist with 131 (34%) patients admitted locally, all of whom had chronic complex conditions (CCC). There was a total of 44 (11%) patients who presented to the PED with de novo issues and had a variety of acute presenting complaints with minor injuries, syncope and chest pain being most common., Conclusion: This is the first Irish study demonstrating a significant population (> 15 years) with medical complexity that requires a suite of services in a paediatric hospital which is accessed in an unscheduled manner through an emergency department. We recommend further research to describe paediatric CCC attending Irish emergency and hospital services.

Introduction: Cross-sectional data of pediatric blunt solid organ injury demonstrates higher rates of nonoperative management and shorter lengths of stay (LOSs) in pediatric trauma centers (PTCs) versus adult trauma centers (ATCs) or dual trauma centers (DTCs). Recent iterations of guidelines (McVay 2008, J Pediatr Surg 2008;43(6):1072-1076 J Trauma Acute Care Surg 2015;79(4):683-693) have emphasized physiologic parameters rather than injury grade in clinical decision making, improving resource allocation and decreasing LOS. We sought to evaluate how these guidelines have influenced care., Methods: The National Trauma Data Bank (2007-2016) was queried for isolated spleen and liver injuries in patients younger than 19 years. Linear regression, odds ratio (OR), and χ test were used to determine significance between operative intervention or LOS among different trauma center types and grade of injury., Result: A total of 55,036 blunt spleen or liver injuries were identified. Although operative rates decreased in ATCs over time (p = 0.037), patients treated at ATCs or DTCs continued to demonstrate higher ORs of operative intervention (OR, 4.43 and 2.88, respectively) compared with PTCs. Mean LOS decreased by 1.52 (p < 0.001), 0.49 (p = 0.26), and 1.31 (p = 0.05) days at ATC, DTC, and PTC to 6.43, 6.68, and 5.16 days. Improvement in LOS for ATCs was distributed across injury Grades I, II, and IV, while there was no correlation among PTCs for injury grade., Conclusion: Despite more than a decade of guidelines in pediatric solid organ injury supporting nonoperative management and accelerated discharge pathways based on physiologic parameters, rates of operative intervention remain much higher in ATCs versus PTCs, and all centers appear to fall short of consensus guidelines for discharge., Level of Evidence: Care management study, level IV.

Aim: To assess the impact of a pilot nurse-led paediatric oncology fast-track clinic (OFTC) for complications and side effects following chemotherapy within a paediatric tertiary hospital., Methods: Prospective clinical data from the first 100 patients seen in the OFTC were compared with retrospective data of oncology patient presentations to the emergency department (ED) (over a 1-year period, n = 196) who would have been eligible for review in the OFTC. Parent and patient satisfaction of clinical care were also assessed via surveys pre- and post-OFTC implementation., Results: Analysis which achieved statistical difference was a reduction in the number of blood tubes taken in OFTC (average 1.9 for those discharged from clinic, 2.9 for those admitted from clinic) in comparison to those seen in the ED (average 3.2) (p = 0.0027). The average number of interventions per patient seen in the ED were 2.1 (standard deviation 1.64) compared with 1.7 (standard deviation 1.55) interventions per patient seen in the OFTC, and who were not admitted following review. This result approached statistical significance with p = 0.0963. Other results which did not meet statistical significance included a reduction in treatment times, hospital admissions and medical oncology reviews., Conclusion: Our pilot study implementing an OFTC for the triage and assessment of chemotherapy-related complications has proven successful from an operational and consumer perspective. The clinic improved care by ensuring expedited review, more streamlined interventions, and less overall hospital admissions. The improvements in efficiency were also mirrored by increased parent and patient satisfaction.

Background: Common cause analysis of hospital safety events that involve radiology can identify opportunities to improve quality of care and patient safety., Objective: To study the most frequent system failures as well as key activities and processes identified in safety events in an academic children's hospital that underwent root cause analysis and in which radiology was determined to play a contributing role., Materials and Methods: All safety events involving diagnostic or interventional radiology from April 2013 to November 2018, for which the hospital patient safety department conducted root cause analysis, were retrospectively analyzed. Pareto charts were constructed to identify the most frequent modalities, system failure modes, key processes and key activities., Results: In 19 safety events, 64 sequential interactions were attributed to the radiology department by the patient safety department. Five of these safety events were secondary to diagnostic errors. Interventional radiology, radiography and diagnostic fluoroscopy accounted for 89.5% of the modalities in these safety events. Culture and process accounted for 55% of the system failure modes. The three most common key processes involved in these sequential interactions were diagnostic (39.1%) and procedural services (25%), followed by coordinating care and services (18.8%). The two most common key activities were interpreting/analyzing (21.9%) and coordinating activities (15.6%)., Conclusion: Proposing and implementing solutions based on the analysis of a single safety event may not be a robust strategy for process improvement. Common cause analyses of safety events allow for a more robust understanding of system failures and have the potential to generate more specific process improvement strategies to prevent the reoccurrence of similar errors. Our analysis demonstrated that the most common system failure modes in safety events attributed to radiology were culture and process. However, the generalizability of these findings is limited given our small sample size. Aligning with other children's hospitals to use standard safety event terminology and shared databases will likely lead to greater clarity on radiology's direct and indirect contributions to patient harm.

Objective : Our hospital's pediatric Emergency Department (ED) began using dexamethasone for treating asthma exacerbations after ED studies showed non-inferiority of dexamethasone compared to prednisone. However, providers have not reached consensus on optimal inpatient steroid regimen. This study evaluates provider preference for inpatient steroid treatment.Methods: A survey was distributed to providers who care for inpatient pediatric asthmatics. Respondents answered questions about steroid choice and timing. Data were summarized as percentages; bivariate comparisons were analyzed with Pearson's chi-squared test. Results : Ninety-two providers completed the survey (60% response rate). When patients received dexamethasone in the ED, subsequent inpatient management was variable: 44% continued dexamethasone, 14% switched to prednisone, 2% said no additional steroids, and 40% said it depended on the scenario. Hospitalists were more likely to continue dexamethasone than pulmonologists (61% and 15%, respectively; p  < .001). Factors that influenced providers to switch to prednisone in the inpatient setting included severity of exacerbation (73%) and asthma history (47%). Fifty-one percent felt uncomfortable using dexamethasone because of "minimal data to support [its] use inpatient." In case-based questions, 28% selected dexamethasone dosing intervals outside the recommended range. Thirteen percent reported experiencing errors in clinical practice. Conclusions : Use of dexamethasone in the ED for asthma exacerbations has led to uncertainty in inpatient steroid prescribing practices. Providers often revert to prednisone, especially in severe asthma exacerbations, possibly due to experience with prednisone and limited research on dexamethasone in the inpatient setting. Further research comparing the effectiveness of dexamethasone to prednisone in inpatient asthmatic children with various severities of illness is needed.

Background: There is increasing interest in finding novel approaches to improve the preparation of children for hospital procedures such as surgery, x-rays, and blood tests. Well-prepared and informed children have better outcomes (less procedural anxiety and higher satisfaction). A digital therapeutic (DTx) platform (Xploro) was developed with children to provide health information through gamification, serious games, a chatbot, and an augmented reality avatar., Objective: This before and after evaluation study aims to assess the acceptability of the Xploro DTx and examine its impact on children and their parent's procedural knowledge, procedural anxiety, and reported experiences when attending a hospital for a planned procedure., Methods: We used a mixed methods design with quantitative measures and qualitative data collected sequentially from a group of children who received standard hospital information (before group) and a group of children who received the DTx intervention (after group). Participants were children aged between 8 and 14 years and their parents who attended a hospital for a planned clinical procedure at a children's hospital in North West England. Children and their parents completed self-report measures (perceived knowledge, procedural anxiety, procedural satisfaction, and procedural involvement) at baseline, preprocedure, and postprocedure., Results: A total of 80 children (n=40 standard care group and n=40 intervention group) and their parents participated in the study; the children were aged between 8 and 14 years (average 10.4, SD 2.27 years) and were attending a hospital for a range of procedures. The children in the intervention group reported significantly lower levels of procedural anxiety before the procedure than those in the standard group (two-tailed t 63.64 =2.740; P=.008). The children in the intervention group also felt more involved in their procedure than those in the standard group (t 75 =-2.238; P=.03). The children in the intervention group also reported significantly higher levels of perceived procedural knowledge preprocedure (t 59.98 =-4.892; P=.001) than those in the standard group. As for parents, those with access to the Xploro intervention reported significantly lower levels of procedural anxiety preprocedure than those who did not (t 68.51 =1.985; P=.05). During the semistructured write and tell interviews, children stated that they enjoyed using the intervention, it was fun and easy to use, and they felt that it had positively influenced their experiences of coming to the hospital for a procedure., Conclusions: This study has shown that the DTx platform, Xploro, has a positive impact on children attending a hospital for a procedure by reducing levels of procedural anxiety. The children and parents in the intervention group described Xploro as improving their experiences and being easy and fun to use., (©Lucy Bray, Ashley Sharpe, Phillip Gichuru, Peter-Marc Fortune, Lucy Blake, Victoria Appleton. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 11.08.2020.)

Background: A positive distraction is a significant environmental feature that introduces positive feelings by diverting attention from stress or anxious thoughts. Existing research has deemed the application of positive distractions in pediatric environments to be significant. This study investigated the essential positive distractions and the associated health benefits., Aims: The aims of this study were to validate and extend evidence on positive distractions and play opportunities in the design of the public spaces in pediatric healthcare environments, translate existing evidence into design suggestions, and identify research gaps in this realm., Methods: A four-phased literature review method was employed in the study, including literature search, literature screening and selection, literature appraisal, and thematic analysis and in-depth discussion. Eventually, 27 peer-reviewed publications were reviewed and discussed in detail., Results/conclusions: The gathered materials were grouped into six themes of positive distractions: (1) art and environmental aesthetics, (2) spatial arrangement and atrium, (3) considerations of socialization patterns, (4) play and interactive technologies, (5) sound and lighting interventions, and (6) access to nature. The research indicated that positive distractions in the pediatric healthcare environment provide a series of health benefits for patients, including improved behavioral and emotional well-being, reduced stress and anxiety, enhanced healthcare experience and satisfaction, and facilitated medical procedures and recovery. Yet significant research gaps emerged between positive distractions and play in garden spaces and spatial design to accommodate interactive technology and socialization in the public areas of pediatric healthcare environments. This study organized the understanding on the components of supportive environments and its outcomes for pediatric healthcare design.

The pandemic of coronavirus SARS-CoV-2 disease affected Northern Italy, spreading from the Bergamo province to the entire country. During reorganization of our emergency department to support patients presenting with coronavirus SARS-CoV-2 disease, we aimed to evaluate whether children play a role in intrahospital spread of the infection., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Clinical pathways (operational versions of practice guidelines) can improve guideline adherence and quality of care for children hospitalized with asthma. However, there is limited guidance on how to implement pathways successfully. Our objective was to identify potential best practices in pathway implementation. Methods: In a previous observational study, we identified higher and lower performing children's hospitals based on hospital-level changes in asthma patient length of stay after implementation of a pathway. In this qualitative study, we conducted semi-structured interviews with a purposive sample of healthcare providers involved in pathway implementation at these hospitals. We used constant comparative methods to develop a conceptual model of potential best practices in implementation. Results: Healthcare providers ( n  = 24) from 6 higher performing and 2 lower performing hospitals were interviewed about pathway implementation. We identified several practices that addressed barriers and promoted successful pathway implementation: (1) utilizing quality improvement (QI) methodology and a data-driven approach helped overcome inertia of current practice; (2) getting teams to commit to shared goals around asthma care helped overcome disagreements in the implementation process; (3) integrating pathways into the electronic medical record decreased some burdens of implementation; (4) leveraging multidisciplinary teams by developing protocols for nurses and/or respiratory therapists to titrate medications reduced variability in provider practice; and (5) engaging hospital leaders with pathway implementation teams helped secure crucial resources. Conclusions: We identified several potential best practices to support pathway implementation. Hospitals implementing pathways should consider applying these strategies to better ensure success in improving quality of asthma care for children.

Introduction: Increasing rates of non-fatal self-harm amongst adolescents represent growing concern. The objective of the study is to describe non-fatal self-harm - including suicidal behaviour (SB), suicidal ideation (SI) and non-suicidal self-injury (NSSI) - observed at an Italian paediatric emergency department (ED)., Methods: Retrospective analysis of the clinical records of patients admitted to ED from 2011 to 2016, who underwent child psychiatry consultation (CPc). We analyzed: rates of CPc for SB, SI and NSSI; risk factors for SB and SI in patients admitted to the hospital's Child Psychiatry Unit after a CPc; and, correlations between NSSI and SB/SI., Results: The rate of CPc for SB, SI and NSSI switched from 7.7% in 2011 to 19% in 2016, with a statistically significant increase over the years (p < 0.001), a 2.2:1 female/male ratio, and an average age of 15.5 ± 1.8 years. SB consisted mainly in drug poisoning (53%), with a significant prevalence in female. Mood disorder was identified in 82.5% of patients hospitalized for SB or SI. Substance abuse was more frequently found in patients admitted for SB when compared to the SI group. Almost half (48%) of the patients admitted for SB or SI reported a current or lifelong history of NSSI. In patients admitted for SB or SI, 3 factors were significantly and independently associated with NSSI: being female, substance abuse, and more severe depressive symptoms., Conclusions: Between 2011 and 2016, there was a significant growing need for CP consultations for suicidal behaviours, mainly in female adolescents. The subjects admitted for SI or SB, who also presented NSSI, were mainly substance abusers, and presented with more severe depressive symptoms.

Background: The objective of our study was to evaluate the clinical utility of rapid sequence magnetic resonance imaging (MRI) utilizing diffusion-weighted imaging and fluid-attenuated inversion recovery sequences in children with acute ischemic strokes and nonstroke brain attacks., Methods: We performed a retrospective chart review of patients aged one month to 25 years for whom a pediatric stroke clinical pathway was activated. Diffusion-weighted imaging and fluid-attenuated inversion recovery were obtained followed by a complete MRI. Imaging was interpreted by a pediatric radiologist and the study neurologist. We collected information regarding patient demographics, neuroimaging results, and final diagnosis., Results: The Pediatric Stroke Clinical Pathway was activated for 59 patients of whom 52 were included for analysis. The majority of patients were female (n = 29, 55.8%) and African American (n = 32, 61.5%), with a median age of 12 years (interquartile range 9, 16). Six patients had an ischemic stroke. Seizures, migraines, and psychosomatic disorders (each with n = 7; 13.5%) were the most common nonstroke diagnoses. Diffusion-weighted imaging was more sensitive (100% [55.0% to 100%] versus 80 % [32% to 99%]) and specific (73.9% [68% to 74%] versus 37.2% [32% to 39%]) compared with fluid-attenuated inversion recovery in identification of an ischemic stroke. However, fluid-attenuated inversion recovery was useful in the identification of inflammatory and metabolic disorders., Conclusion: Rapid sequence MRI can be utilized as a screening imaging modality in children with suspected brain attacks in cases where there may be delays in obtaining full sequence brain imaging., (Published by Elsevier Inc.)

Study Objective: A gap analysis of emergency departments' (EDs') pediatric readiness across a health system was performed after the appointment of a service line health system pediatric emergency medicine (PEM) quality director., Methods: A 55-question survey was completed by each eligible ED to generate a weighted pediatric readiness score (WPRS). The survey included questions regarding volume, ED configuration, presence of a pediatric emergency care coordinator (PECC), quality initiatives, policies and procedures, and equipment. Surveys were completed from June 1 to November 12, 2016.Analysis of variance was used to compare the 4 groups of EDs based upon their annual pediatric volume as a continuous measure (low, <1800 visits; medium, 1800-4999 visits; medium-high, 5000-9999 visits; high, >10,000 visits). The Fisher exact test was used to compare the 4 groups for the remaining categorical variables represented as frequencies and percentages. A result was considered statistically significant at the P < 0.05 level of significance., Results: There were a total of 16 hospitals (after the exclusion of the children's hospital, the hub for pediatric care in the health system, and 1 adult-only hospital) with the following pediatric capability: 7 basic (no inpatient pediatrics), 7 general (inpatient pediatrics, with/without a neonatal intensive care unit), and 2 comprehensive (inpatient pediatrics, pediatric intensive care unit, and a neonatal intensive care unit). In 12 EDs, adults and children are treated in the same space. These EDs see a total of 800,000 annual visits including 120,000 pediatric visits. Two low pediatric volume EDs had a median WPRS of 69, range of 62 to 76 (national median, 61.4); 6 medium pediatric volume EDs had a median WPRS of 51, range of 42 to 81 (national median, 69.3); 4 medium-high pediatric volume EDs had a median WPRS of 69.3, range of 45 to 98 (national medium, 74.8); 4 high pediatric volume EDs had a WPRS score of 84.5, range of 58 to 100 (national medium, 89.8). There were 4 sites with PECCs: 1 medium-high volume and 3 high volume, with a median WPRS of 98.5, range of 81 to 100 (national medium, 89.8). Two low-volume EDs have Neonatal Resuscitation Program training for nurses (P < 0.0083). One medium-high volume ED requires specific pediatric competency evaluations for advanced level practitioners staffing the ED. Pediatric-specific quality programs are present in the 2 low volume EDs, 3 of the 6 EDs in the medium group, 3 of 4 EDs in the medium-high group, and all 4 high volume hospitals. After the implementation of the health system PEM quality director, all EDs have a doctor and nurse PECC with a median WPRS of 81. In additiona, a committee was formed with the following key stakeholders: PECCs, pediatric nursing educators, pediatric quality, pharmacy, obstetrics, behavioral health, and neonatology. The committee is part of the health system quality program within both pediatrics and emergency medicine and is spearheading the standardization of code carts and medications, dissemination of pediatric clinical guidelines, and the development of a pediatric quality program across the health system., Conclusions: Pediatric emergency care coordinators play an important role in ED readiness to care for pediatric patients. In a large health system, a service line PEM quality director with the support of emergency medicine and pediatrics, a committee with solid frontline ED base, and a diverse array of stakeholders can foster the engagement of all EDs and improve compliance with published guidelines.