Faculty Bibliography

Introduction/UNASSIGNED:Patient-family-centered care (PFCC) is based on the understanding that the family is the child's source of strength and support. Effective communication between families and providers is an essential component of PFCC. Our interprofessional team designed an initiative to improve medical providers' communication in partnership with the Patient and Family Advisory Council (PFAC). Strategies included the creation of a competency rubric and simulation curriculum using the family as faculty. The SMART aim was to improve the percentage of respondents who answered "Always" to doctor communication domains from 72% to 75.6% in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) by December 2020. Methods/UNASSIGNED:Pediatric residents, medical students, faculty, nurses, and PFAC members formed a Quality Improvement (QI) team to address PFCR competency. The team created a PFCC checklist to address competency. PFAC volunteers served as standardized parents in an in situ simulation of PFCR scenarios involving interprofessional in-patient teams. Evaluators observed rounds for the pre and postintervention assessment using the checklist. The outcome measure was the percentage of respondents who answered "Always" in the HCAPHS domain for physician communication. The process measure was the PFCR pre and postintervention, using Fisher's exact test for analysis. Results/UNASSIGNED:Using a statistical process chart (SPC), HCAHPS data from 2018 to 2020 showed that we exceeded our aim of >5% increase in the physician communication performance. Pre-post intervention data showed improvement in PFCR competency. Conclusion/UNASSIGNED:Family as faculty simulation led to improved physician communication, translating to improved performance in the HCAHPS score and PFCR competency communication domains.

Objective The use of high-flow nasal cannula (HFNC) as non-invasive respiratory support in children with bronchiolitis has increased over the last several years. Several studies have investigated enteral feeding safety while on HFNC. This study compares the safety of oral feeding prior to and following implementation of an HFNC feeding guideline. Patients and methods A retrospective study was designed, in children ≤2 years of age with bronchiolitis, requiring HFNC, from 2017 to 2019. We defined feeding complications on HFNC and defined safety as the absence of such complications. We gathered the following data: oral feeding timing from the HFNC initiation, duration of enteral feeding on HFNC, and HFNC flow rate at which the feeding was initiated. We compare the data prior to and post-implementation of an HFNC feeding guideline. Results Descriptive statistics were calculated separately by pre and post guideline implementation. Patients in both pre and post guideline implementation groups had no feeding complications on HFNC. Subjects in the post (n=50) vs. pre-guideline implementation (n=36) had a higher median amount of liters flow when initiating enteral feeding (8.0 vs. 6.0 respectively, p<0.024), spent fewer days in the pediatric intensive care unit (PICU) (two days vs. 0 days). Post guideline implementation, enteral feeding was initiated sooner (days nil per os [NPO] 1.0 vs 2.0). No other significant differences between the two cohorts with respect to other variables were observed.  Conclusions Our data supports that oral feeding in patients with bronchiolitis on HFNC is safe. Utilization of current guidelines allowed safe earlier feeding of children on HFNC, reducing the time spent NPO.

Background/UNASSIGNED:Children with sickle cell disease experience vaso-occlusive crises (VOC) that requires opioid pharmacotherapy. Multimodal analgesic therapy may reduce pain and opioid-induced adverse effects. Objective/UNASSIGNED:The primary objective was to examine the effectiveness of intravenous (IV) acetaminophen in children presenting with pain from VOC. Secondary objectives were to document the safety and opioid-sparing effects of IV acetaminophen during VOC in pediatric patients. Setting/UNASSIGNED:Children's Medical Center, NYU-Winthrop Hospital. Method/UNASSIGNED:This retrospective study had two groups of patients, those who received opioids alone (group O) and those who received acetaminophen with opioids (group OA). Children two to 19 years of age who were admitted to the children's medical center for VOC were eligible for inclusion. Main outcome measure/UNASSIGNED:A reduction in pain by at least 1 out of 10. With every analgesic dose, we documented pain scales and pain scores before and after each dose, the number of doses administered per day, and mg/kg/day. Data were analyzed using the mixed effect model. All opioids administered to patients were converted to morphine equivalents. We documented length of stay and adverse events. Results/UNASSIGNED:= 0.066), and opioid-related adverse effects. Conclusion/UNASSIGNED:This is the first study to demonstrate the effectiveness of IV acetaminophen in treating VOC pain in children, supporting multimodal analgesic therapy in this setting. Opioid-sparing effects were also encouraging.

BACKGROUND:Research suggests pediatrics practitioners lack confidence and skills in the end-of-life (EOL) care. OBJECTIVE:This pilot study explored the impact of a curriculum designed to prepare future pediatricians to manage pain and provide comfort for children and infants with life-threatening conditions and to be more confident and competent in their EOL discussions with families. METHODS:Participants included 8 postgraduate year (PGY)-2 residents in the study group and 9 PGY-3 residents in a control group. The EOL curriculum included 4, 1-hour sessions consisting of didactic lectures, videos, and small-group, interactive discussions. Topics included discussing EOL with families, withdrawal of care, and pain assessment and management. Curriculum evaluation used an objective structured clinical examination (OSCE), self-assessment confidence and competency questionnaire, and a follow-up survey 18 months after the intervention. RESULTS:The OSCE showed no statistically significant differences between PGY-2 versus PGY-3 residents in discussing EOL issues with family (mean  =  48.3 [PGY-2] versus 41.0 [PGY-3]), managing withdrawal of care (mean  =  20.9 [PGY-2] versus 18.91 [PGY-3]), and managing adolescent pain (mean  =  30.97 [PGY-2] versus 29.27 [PGY-3]). The self-assessment confidence and competency scores improved significantly after the intervention for both PGY-2 residents (0.62 versus 0.86, P < .01) and PGY-3 residents (0.61 versus 0.85, P < .01). CONCLUSIONS:An EOL curriculum for PGY-2 pediatrics residents delivered during the intensive care unit rotation is feasible and may be effective. Residents reported the curriculum was useful in their practice.

INTRODUCTION/BACKGROUND:Is the prehospital care of injured children comparable with adult standards? This question has been asked repeatedly by many clinicians, yet there are no definite answers. OBJECTIVE:To evaluate the prehospital care provided by first responders to pediatric patients (<12 yrs of age) with head injury compared with the adult group (>12 yrs of age) to determine whether the emergency medical services providers are able to adequately assess the children and provide emergency services comparable with adult standards. PATIENTS AND METHODS/METHODS:A retrospective 4-yr review of pediatric (n = 102) and adult (n = 99) patients with head injury and Glasgow coma scale score <15 who were treated at a level 1 trauma center. Emergency medical service interventions such as intravenous access, endotracheal intubation, and fluid resuscitation were reviewed. Patients who required further intervention on arrival at the trauma center either from nonperformance of a required procedure or complications arising from such procedures were documented. MAIN RESULTS/RESULTS:There were 102 pediatric and 99 adult patients included in the final analysis. Injury severity based on Glasgow coma scale score was not different between the groups. A total of 91 patients, 52 adults (52.5%) and 39 children (38.2%), needed endotracheal intubation at the scene. Significantly more pediatric patients had problems with intubation, 27 children (69.2%) vs. 11 adults (21.2%), p < .001.Intravenous access was successfully established in 85.9% of adults compared to 65.7% in children at the scene (p = .001). Consequently, on arrival at the trauma center, more children required intravenous access, 80.4% compared with 63.6% for adults (p = .011). As a result, more children (25.5%) required initial or additional fluid bolus at the trauma center compared with adults (9.1%, p = .003). CONCLUSIONS:Prehospital care of children is suboptimal compared with adults in areas of endotracheal intubation, establishment of peripheral intravenous access, and fluid resuscitation.

Here we describe a case of propofol-related infusion syndrome (PRIS) in a child with malignant refractory status epilepticus treated with partial-exchange blood transfusion (PEBT), an innovative method of resuscitation that has the potential to reduce the mortality rate associated with this syndrome. Our patient is a 4-year-old boy with malignant status epilepticus associated with bacterial meningitis. Propofol was used because of persistent seizure activity refractory to adequate doses of phenytoin, phenobarbital, levetiracetam, and midazolam infusion at 0.7 mg/kg per hour. Propofol was escalated from 0.6 mg/kg per hour to an electroencephalogram-burst-suppressing dose of 15.6 mg/kg per hour. Signs of PRIS were noticed after 48 hours on propofol. The severe bradycardia responded only to infusions of calcium gluconate. PEBT corrected all the cardiac abnormalities and returned enough hemodynamic stability to permit continuous veno-venous hemodialysis for renal failure and removal of toxins. PEBT is a safe and innovative option for correcting the metabolic abnormalities that result in cardiac dysfunction, which is typically the most serious and usually terminal event in PRIS. When done with small aliquots, it avoids the severe hemodynamic instability that is usually a hindrance with hemodialysis, continuous veno-venous hemodialysis, and extracorporeal membrane oxygenation, which are other methods of supporting these children during the crisis that are mentioned in the literature.