Faculty Bibliography

PURPOSE/OBJECTIVE:The benefits of hospitalist co-management of pediatric surgical patients include bettering patient safety, decreasing negative patient outcomes, providing comprehensive medical care, and establishing a dedicated resource to patients for postoperative care. The purpose of this study was to characterize the nature of patients co-managed by a pediatric hospitalist. The authors hypothesize that hospitalist co-management is safe and efficacious in pediatric orthopaedic surgical patients who are admitted to a community hospital. METHODS:A retrospective review was performed of all pediatric orthopaedic surgical patients admitted to a community hospital who were co-managed by a pediatric hospitalist. Indications for hospitalization included pain control, antibiotic infusion, and need for neurovascular monitoring. Parameters of postoperative care and co-management were assessed, including presence of complications, medication introduction or adjustment by the hospitalist, follow-up adherence, and readmission/complication rates after discharge. RESULTS:Thirty-two patients were assessed with an average age of 8.8 years. Twenty-five percent of patients had an associated comorbidity, including asthma, attention deficit disorder, and/or autism. The pediatric hospitalist added pain medication to the original postoperative orders placed by the orthopaedics team in 44 percent of patients (14 of the 32) either for breakthrough pain or better long-term coverage. Additionally, 25 percent of patients had pain medication adjusted from the original dosing and schedule. The hospitalist team contacted the surgeon about the four patients (12.5 percent). In three of the cases, the surgeon was contacted to discuss pain medication, and one patient woke up agitated from anesthesia, necessitating a visit from the surgeon on the pediatrics floor. The length of stay was one day for all patients. The hospitalists rounded on and discharged patients the subsequent morning. All patients were given a follow-up appointment and schedule by the hospitalist team, and every patient followed up accordingly within ten days of discharge. No complications or hospital readmissions occurred within thirty days of discharge. CONCLUSION/CONCLUSIONS:Hospitalist co-management of pediatric orthopaedic surgical patients in a community hospital allows for better medical comorbidity and medication management. Hospitalists can provide closer observation during the inpatient stay and help streamline communication between providers and patients while allowing the surgeon the ability to be more mobile. Co-management is safe and efficacious in pediatric orthopaedic surgical patients who are admitted to a community hospital.

BACKGROUND: Central venous catheters are crucial devices in the care of hospitalized children, both in and out of critical care units, but the concomitant risk of central line-associated bloodstream infection (CLABSI) affects 15,000 Americans annually. In 2012, CLABSI rates varied among units from 6.8/1,000 to 1.0/1,000 in a 109-bed children's service within NYU Langone Medical Center (NYULMC; New York City), a 1,069-bed tertiary care academic medical center. In response to variation in central line-related practices and infection prevention rates, a CLABSI Prevention Core Team began an effort to standardize central venous catheter (CVC) care across all pediatric units (ICU and non-ICU). Momentum in this quality improvement (QI) work was interrupted when Superstorm Sandy shuttered the flagship hospital, but the relatively decreased clinical load provided a "downtime" opportunity to address CLABSI prevention. METHODS: The first phase of the collaborative effort, Booster 1, Planning/Initial Phase: Development of a Pediatric Central Venous Catheter Working Group, was followed by Booster 2, Maintenance/Sustaining Phase: Transitioning for Sustainability and Adopting Model for Improvement. RESULTS: Data in the subsequent 21 months after the temporary closure of the facility (January 2013-September 2014) showed an increase in maintenance bundle reliability. The inpatient CLABSI rate for patients < 18 years decreased from an annual rate of 2.7/1,000 line days (2012) to 0.6/1,000 line days (2013) to 0.5/1,000 line days as of August 2014. There was a decrease in pediatric CLABSI events and no significant change in line days. CONCLUSIONS: Key elements contributing to initial success with evolving QI capacity and resources were likely multi-factorial, including staff and leadership engagement, culture change, consistent guidelines, and accountability by individuals and by our multidisciplinary core team.

On October 29, 2012, Hurricane Sandy made landfall in the neighborhood of Red Hook in Brooklyn, New York. The massive tidal surge generated by the storm submerged the coastal area, home to a population over 11,000 individuals, including the largest public housing development in Brooklyn. The infrastructure devastation was profound: the storm rendered electricity, heat, water, Internet, and phone services inoperative, whereas local ambulatory medical services including clinics, pharmacies, home health agencies, and other resources were damaged beyond functionality. Lacking these services or lines of communication, medically fragile individuals became isolated from the hospital and 911-emergency systems without a preexisting mechanism to identify or treat them. Medically fragile individuals primarily included those with chronic medical conditions dependent on frequent and consistent monitoring and treatments. In response, the Red Hook community established an ad hoc volunteer medical relief effort in the wake of the storm, filling a major gap that continues to exist in disaster medicine for low-income urban environments. Here we describe this effort, including an analysis of the medically vulnerable in this community, and recommend disaster risk reduction strategies and resilience measures for future disaster events. (Disaster Med Public Health Preparedness. 2015;9:354-358).

Comanagement of surgical patients is occurring more commonly among adult and pediatric patients. These systems of care can vary according to institution type, comanagement structure, and type of patient. Comanagement can impact quality, safety, and costs of care. We review these implications for pediatric surgical patients.

Background/Purpose: Pediatric cleft lip and palate surgery can be stressful for both the child and the parents. Limited pain knowledge and certain parent psychological traits are associated with increased parental anxiety around surgery in older children. Increased parental anxiety has been associated with increased child pain, decreased ability of the child to cope with pain and worse outcomes in other surgical settings. Little is known about parental anxiety and child pain in preverbal children undergoing cleft lip and palate repair. The objectives of this study were to explore possible sociodemographic factors contributing to parental anxiety in the immediate postoperative period and to determine if there is a relationship between parental postoperative anxiety and infant postoperative pain. Methods/Description: Cross-sectional pilot study, semi-structured interview. Eight mothers of children under 18 months of age undergoing cleft lip/palate (CL/P) repair at an urban craniofacial center were recruited. Semi-structured interviews about their experience with their infant's surgery were conducted. Demographics were collected at a preoperative visit, while maternal anxiety scores, measured using the Hospital Anxiety and Depression Scale (HADS), and nurse-recorded child pain scores (Face, Legs, Activity, Cry, Consolability scale), were collected on postoperative day (POD) 1. Fisher's exact tests were used to compare demographics and Student's t-tests were used to analyze pain medication and doses given. Results: Mothers who were healthcare workers were more likely to have borderline/abnormal anxiety scores (HADS > 7) than mothers who were non-healthcare workers (p = .035) on POD1. Mothers of infants undergoing a bilateral CL/P repair tended to be more anxious than mothers of infants undergoing a unilateral CL/P repair (p=.090). Infants of anxious mothers tended to have more variation in pain scores, more pain scores recorded (95% CI -1.74, 4.0) (p = .19) and more pain medication given (95% CI 2.!