Faculty Bibliography

BACKGROUND:Central line-associated bloodstream infections (CLABSIs) are major contributors to preventable harm in the inpatient paediatric setting. Despite multiple guidelines to reduce CLABSI, sustaining reliable central line maintenance bundle compliance remains elusive. We identified frontline and family engagement as key drivers for this initiative. The baseline CLABSI rate for all our paediatric inpatient units (January 2016-January 2017) was 1.71/1000 central line days with maintenance bundle compliance at 87.9% (monthly range 44%-100%). OBJECTIVE:To reduce CLABSI by increasing central line maintenance bundle compliance to greater than 90% using kamishibai card (K-card) audits and family 'key card' education. METHODS:We transitioned our central line maintenance bundle audits from checklists to directly observed K-card audits. K-cards list the central line maintenance bundle elements to be reviewed with frontline staff. Key cards are cue cards developed using a plain-language summary of CLABSI K-cards and used by frontline staff to educate families. Key cards were distributed to families of children with central lines to simultaneously engage patients, families and frontline staff after a successful implementation of the K-card audit process. A survey was used to obtain feedback from families. RESULTS:In the postintervention period (February 2017-December 2019), our CLABSI rate was 0.63/1000 central line days, and maintenance bundle compliance improved to 97.1% (monthly range 86%-100%, p<0.001). Of the 45 family surveys distributed, 20 (44%) were returned. Nineteen respondents (95%) reported being extremely satisfied with the key card programme and provided positive comments. CONCLUSION/CONCLUSIONS:Combining the key card programme with K-card audits was associated with improved maintenance bundle compliance and a reduction in CLABSI. This programme has the potential for use in multiple healthcare improvement initiatives.

OBJECTIVE:To assess the impact of separation of SARS-CoV-2 PCR-positive mother-newborn dyads on breastfeeding outcomes. STUDY DESIGN/METHODS:This is an observational longitudinal cohort study of SARS-CoV-2 PCR-positive mothers and their infants at three NYU Langone Health hospitals from March 25, 2020 through May 30, 2020. Mothers were surveyed by telephone regarding pre-delivery feeding plans, in-hospital feeding, and home feeding of their neonates. Any change prompted an additional question to determine whether this change was due to COVID-19. RESULTS:Of the 160 mother-newborn dyads, 103 mothers were reached by telephone, and 85 consented to participate. No significant difference was observed in pre-delivery feeding plan between the separated and unseparated dyads (P = .268). Higher rates of breastfeeding were observed in the unseparated dyads compared with the separated dyads in the hospital (p<0.001), and at home (p=0.012). Only two mothers in each group reported expressed breast milk as the hospital feeding source (5.6% of unseparated vs 4.1% of separated). COVID-19 was more commonly cited as the reason for change among the separated compared with the unseparated group (49.0% vs 16.7%, p<0.001). When dyads were further stratified by symptom status into four groups (asymptomatic separated, asymptomatic unseparated, symptomatic separated, and symptomatic unseparated), results remained unchanged. CONCLUSION/CONCLUSIONS:In the setting of COVID-19, separation of mother-newborn dyads impacts breastfeeding outcomes, with lower rates of breastfeeding both during hospitalization and at home following discharge compared with unseparated mothers and infants. No evidence of vertical transmission was observed; one case of postnatal transmission occurred from an unmasked symptomatic mother who held her infant at birth.

Introduction/UNASSIGNED:Premature babies are at increased risk of hypothermia, core body temperature <97°F. Delivery room environment may contribute and lead to complications. The objective was to reduce hypothermia in babies <32 weeks of gestation in the delivery room to <40% using a checklist and sustain it for 6 months. Methods/UNASSIGNED:We created a delivery room checklist in 2012. Chart review established a baseline rate of hypothermia (<97°F). The team analyzed the checklist's effect on hypothermia from 2012 to 2018 and utilized numerous interventions to maintain compliance. Chi-square test and Fisher's exact test analyzed hypothermia and hyperthermia as a balancing measure. All calculations performed in SAS 9.3. Results/UNASSIGNED:The checklist reduced hypothermia from a baseline of 50% in 2011 (n = 104) to 33% in 2012 (n = 106). In 2013, the proportion of hypothermia slightly increased to 36% (n = 81). The year 2014 brought larger drift, and proportion of hypothermia increased to 44% (n = 117). In 2015, we reinforced the use of the checklist and proportion of hypothermia improved to 36% (n = 99). Further interventions through 2018 decreased hypothermia further to 14% to achieve statistical significance. Conclusions/UNASSIGNED:A checklist is a simple tool that may yield beneficial changes in practice and helped to decrease the proportion of neonatal hypothermia.

Objective/UNASSIGNED:The increased incidence of multidrug-resistant organisms is associated with increased morbidity, mortality, hospital length of stay, and cost. Estimates show that up to 50% of antimicrobial use is inappropriate. This initiative focuses on inappropriate use of antibiotics in respiratory syncytial virus (RSV) infections. This virus is the most common cause of bronchiolitis during childhood. Methods/UNASSIGNED:Baseline data from the 2011-2012 RSV season showed that 56.2% of our RSV-positive patients received antibiotics. To decrease inappropriate antibiotic use in RSV infections, we established an antimicrobial stewardship program (ASP). This process improvement initiative aimed to decrease exposure to antibiotics and days of antibiotic therapy per 1,000 patient days (DOT/1000PD) in hospitalized RSV-positive patients by 25%. Key drivers included building health-care knowledge, proactive interventions using prospective audit and feedback, emergency department engagement, and performance dashboards. Results/UNASSIGNED:= 0.017). This change represents a reduction of 164.6 DOT/1000PD from baseline after full ASP implementation. Conclusion/UNASSIGNED:Despite the lack of a unified hospitalist group in our institution, we were successful in reducing inappropriate antibiotic use by focusing on standardizing care among different private pediatricians in the community. A multifaceted strategy and well-designed quality improvement methodology led to a sustained reduction in antibiotic use.

BACKGROUND:Although histologic chorioamnionitis (HCA) is known to be associated with poor outcomes in preterm infants, its clinical significance among term infants is not clearly known. OBJECTIVES/OBJECTIVE:To investigate the utility of HCA in determining early onset clinical sepsis (EOCS) among term newborns. METHODS:The incidence of HCA and EOCS in term infants born during 2008-2009 was evaluated in a single center retrospective study (n = 3417). The predictive value of HCA for determining EOCS in term infants admitted to the neonatal intensive care unit (NICU) for suspected sepsis (n = 388) was quantified. Outcome of otherwise healthy term infants in the nursery with HCA was also investigated. RESULTS:Overall, 11% of term infants with HCA also had EOCS. HCA was associated with increased risk for EOCS (OR 2.6, 95% confidence interval 1.6-4.2, P < 0.001) among term infants admitted to the NICU for suspected sepsis. No cases of EOCS were found among otherwise well-appearing infants in the nursery with HCA. Multiple logistic regression analysis indicated that addition of HCA does not increase the power of a model combining C-reactive protein (CRP) and immature to total neutrophil ratio in determining EOCS. CONCLUSION/CONCLUSIONS:Although HCA in term infants is associated with EOCS, it did not improve the ability of CRP and immature to total neutrophil ratio to predict EOCS. Routine placental examination may not contribute to the diagnosis of EOCS in term infants.

OBJECTIVE:Associations between pleural and pericardial effusions have been described in malignancy and autoimmune disorders. Bacterial pneumonia is the most frequent cause of parapneumonic effusion; however, knowledge of the relationship between parapneumonic effusion and the presence of pericardial fluid in children is limited. We examined this relationship. METHODS:We performed a retrospective chart review of pediatric patients who were admitted to our institution during a 6-year period with a diagnosis of either parapneumonic effusion or empyema and who had undergone an echocardiogram, a computed tomography scan of the thorax, or both. All demographic, clinical, radiographic, and laboratory data of these patients were collected, and statistical analysis was done with Student's t tests and chi2 analyses. RESULTS:We reviewed the charts of 59 children with parapneumonic effusions. Forty-eight underwent 2-dimensional echocardiography, chest computed tomography scan, or both. Of these 48 patients, 54.2% (n=26) were found to have a concomitant pericardial effusion. The majority of patients with pericardial effusions had left-sided pleural disease. Patients with pericardial effusions had more symptomatic days before hospitalization, lower pleural fluid albumin levels, elevated serum white blood cell counts, elevated pleural fluid white blood cell and absolute neutrophil counts, and an increased incidence of surgical intervention. One patient had evidence of hemodynamic compromise that required pericardiocentesis. CONCLUSIONS:We found a high incidence of pericardial effusions in pediatric patients with parapneumonic effusions. Leukocytosis, higher pleural fluid leukocyte and neutrophil counts, and a propensity for surgical intervention suggest a prognostic relationship between pericardial effusions and more severe parapneumonic disease. The majority of these pericardial collections resolve with treatment of the underlying pleural disease.

Impaired neovascularization is associated with the pathologic presentation of bronchopulmonary dysplasia (BPD). To determine if neovascularization and factors that negatively influence blood vessel formation play a role in the evolution of BPD, we examined the temporospatial distribution of a protein known to inhibit fetal lung neovascularization with associated dysplastic lung formation, endothelial-monocyte activating polypeptide (EMAP) II. Immunohistochemical analysis of EMAP II in lung tissues of human infants with BPD indicated an elevation in EMAP II abundance as compared with control. Utilizing a baboon model, western analysis indicated that EMAP II was increased twofold in those baboons with pathologic signs of BPD as compared with gestational controls. Consistent with our findings in human tissues, immunohistochemistry and in situ hybridization demonstrate that EMAP II is highly expressed in the perivascular stroma and dysplastic lung periphery in neonatal baboons with BPD as compared with controls. Lastly, there is a premature acceleration in EMAP II's perivascular distribution in term newborn baboon as compared with gestational control. The marked increase in EMAP II's temporal expression, its distribution in the perivascular and dysplastic alveolar regions of the lungs, and the interruption in vasculogenesis in BPD suggest that neovascularization and factors that negatively influence blood vessel formation may play a role in BPD evolution.