Faculty Bibliography

STUDY DESIGN: Comparative effectiveness database study. OBJECTIVE: To describe variation in use of adjuvant therapies for managing postoperative pain in in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic (AIS) and determine association between use of these therapies and patient outcomes. SUMMARY OF BACKGROUND DATA: Variation in postoperative pain management for children undergoing PSF for AIS likely impacts outcomes. Minimal evidence exists to support strategies that most effectively minimize prolonged intravenous (IV) opioids and hospitalizations. METHODS: We included patients aged 10-18 years discharged from one of 38 freestanding children's hospitals participating in a national database from 1/12/2012-5/1/2015 with ICD9 codes indicating scoliosis and PSF procedure. Use of ketorolac, GABA analogues (GABAa), and benzodiazepines was compared across hospitals. Hierarchical logistic regression adjusting for confounders and accounting for clustering of patients within hospitals was used to estimate association between these therapies and odds of prolonged duration of IV opioids, prolonged length of stay (LOS), and early readmissions. RESULTS: Across hospitals, use of ketorolac and GABAa was highly variable and increased over time among 7349 subjects. Use of ketorolac was independently associated with significantly lower odds of prolonged LOS (OR 0.75, 95% CI 0.64, 0.89) and prolonged duration of IV opioid (OR 0.84, 95% CI 0.73, 0.98). GABAa use was significantly associated with decreased odds of prolonged IV opioid use (OR 0.63, 95% CI 0.53, 0.75). Readmission rate at 30d was 1.6% and most strongly associated with prolonged LOS. CONCLUSION: In this national cohort of children with AIS undergoing PSF, patients who received postoperative ketorolac or GABAa were less likely to have prolonged IV opioid exposure. Given the rapid increase in use of adjuvant therapies without strong evidence, resources should be devoted to multi-center trials in order to optimize effectiveness and outcomes. LEVEL OF EVIDENCE: 3.

Background/Purpose: Parent anxiety can affect infant experiences of procedural pain. However, little is known about other parent psychological factors associated with parent anxiety related to infant/toddler cleft and craniofacial surgery, and to what degree preoperative parent anxiety affects infant/toddler experiences of postoperative pain. Objectives 1. To identify psychological factors associated with preoperative anxiety for parents with young infants/toddlers undergoing craniofacial surgery 2. To determine whether preoperative parent anxiety is associated with infant/toddler postoperative pain Methods/Description: This was a prospective cohort study of all patients undergoing primary cleft and craniofacial surgery at a tertiary care medical center. Seventy-one consecutive parents of infants/toddlers 2-18 months were recruited for this study. Preoperative parent assessment included: anxiety (Hospital Anxiety and Depression Scale [HADS]), coping (Brief COPE), Parent Health Locus of Control scale, de novo self-efficacy around child pain, and pain knowledge. Sociodemographic data included child's age, gender; previous surgery, NICU or feeding tube; and parent age, gender, socioeconomic status, and race. Subsequent nurse-assessed child pain scores were collected for patients admitted postoperatively. Analyses included hierarchical multivariable logistic and linear regression models. Results: Parents (n=71, 90% female) of young children (mean age 6.6 mo) undergoing cleft lip/palate (n=59) or cranial vault repair (n=13) were enrolled. Only maladaptive coping (OR 1.3, p<0.01, 95% CI 1.1, 1.6), low pain management parent self-efficacy (OR 2.4, p<0.01, 95% CI 1.3, 4.5), and external locus of control (1.74, p 0.024, 95% CI 11, 2.9) were associated with high anxiety on bivariable analysis. In the final model, odds of parent preoperative anxiety was associated with differences in maladaptive coping score (aOR). Moderate/severe preoperative parental anxiety (HADS>10) was correlated with significantly higher child mean hospital pain scores in families of children undergoing cleft lip repair (1.87 point on 0-10 scale, 95% CI.42, 3.70, p =0.045). Conclusions: Infants/toddlers undergoing cleft and craniofacial surgery with highly anxious parents prior to surgery are at greater risk for higher hospital pain. Coping and self-efficacy are modifiable factors that contribute to parent anxiety before and during hospitalization and may be targets for intervention. Health locus of control could be incorporated into preoperative screening for vulnerable families

This study explored parents' perspectives regarding their involvement in safety for their hospitalized children. We employed qualitative description and semistructured interviews of parents of children in an urban tertiary hospital ward. Content analysis revealed 4 parent themes: risks to child safety and comfort, hospital role as a protector, participation in safety varies by individual and organizational factors, and balancing safety with "speaking up" interpersonal risks. We suggest key concepts to incorporate into staff education and family engagement/safety programs to develop effective partnerships between clinicians and parents.

Background. We have recently observed an increase in community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections among pediatric patients from Brooklyn hospitalized at a university-based teaching hospital in New York City. We performed a prospective study to determine the colonization prevalence of CA-MRSA among hospital admission, genome sequence strains causing infection and identified risk factors associated with CA-MRSA carriage in this population. Methods. Colonization data were obtained from routine infection control screening upon admission to the general pediatric and intensive care units. We used a questionnaire to identify risk factors for MRSA transmission. Additionally, single patient isolates of CA-MRSA were collected from the clinical microbiology laboratory. Medical record information was used to ascertain patient infection or colonization and to confirm community onset. Children from high-risk communities were identified via zip codes. Figure. Phylogenetic tree of clinical MRSA USA300 isolates from children living in high-risk zip codes (red), adult and pediatric patients at NYU Tisch Hospital (Blue), and USA300 Strains from around the United States (Green; Pfizer). Results. Children from the high-risk zip codes were 3 times as likely to be colonized with MRSA (9% versus 3% [p = 0.04]). No difference in methicillin-susceptible S. aureus colonization prevalence was observed between children from high-risk and low-risk communities. Likewise, the MRSA infection rate per 1000 patient days was 36 for children from high-risk zip codes, and 3.9 in children from low-risk zip codes (p < 0.0001). All isolates from patients in high risk zip codes analyzed to date belong to genotype USA300, the predominant CA-MRSA clone in the United States. Phylogenetic analyses suggest that these strains arose from expansion of an USA300 CAMRSA subclone. Potential risk factors for MRSA infection are being explored in conjunction with public health and community leaders. Conclusion. We identified a cluster of CA-MRSA strain USA300 among pediatric patients in a high risk Brooklyn community. Additional genomic comparisons and epidemiological data will be used to inform interventions and interrupt transmission. (Figure Presented)

BACKGROUND AND OBJECTIVES: Pediatric procedural pain management (PPPM) is best practice but was inconsistent in our large multisite general academic medical center. We hypothesized that quality improvement (QI) methods would improve and standardize PPPM in our health system within inpatient pediatric units. We aimed to increase topical anesthetic use from 10% to 40%, improve nursing pediatric pain knowledge, and increase parent satisfaction around procedures for children admitted to a general tertiary academic medical center. METHODS: We used QI methods including needs assessment, self-identified champions, small tests of change, leadership accountability, data transparency, and a train-the-peer-trainer approach to implement PPPM. We measured inpatient use of topical anesthetic (goal of 40% of admissions), nursing pain knowledge, and parent satisfaction with child comfort during procedures. We used statistical process control and basic statistics to analyze data in this interrupted time series design. RESULTS: Over 18 months, use of topical lidocaine rose from 10% to 36.5% for all inpatient admissions, resulting in a centerline shift. Nursing pain knowledge scores increased 7%. Mean parent satisfaction around procedural comfort increased from 83% to 88%. CONCLUSIONS: A child-focused QI initiative around PPPM can succeed in a multisite general academic medical center. Key success factors for this effort included accountability, multidisciplinary core leadership, housewide training in a novel educational evidence-based framework, and use of data and champions to promote nurse and physician engagement. Future work will focus on sustaining and monitoring change.

BACKGROUND AND OBJECTIVE: Early identification and treatment of severe sepsis and septic shock improves outcomes. We sought to identify and evaluate children with possible sepsis on a pediatric medical/surgical unit through successful implementation of a sepsis identification pathway. METHODS: The sepsis identification pathway, a vital sign screen and subsequent physician evaluation, was implemented in October 2013. Quality improvement interventions were used to improve physician and nursing adherence with the pathway. We reviewed charts of patients with positive screens on a monthly basis to assess for nursing recognition/physician notification, physician evaluation for sepsis, and subsequent physician diagnosis of sepsis and severe sepsis/septic shock. Adherence data were analyzed on a run chart and statistical process control p-chart. RESULTS: Nursing and physician pathway adherence of >80% was achieved over a 6-month period and sustained for the following 6 months. The direction of improvements met standard criteria for special causes. Over a 1-year period, there were 963 admissions to the unit. Positive screens occurred in 161 (16.7%) of these admissions and 38 (23.5%) of these had a physician diagnosis of sepsis, severe sepsis, or septic shock. One patient with neutropenia and septic shock had a negative sepsis screen due to lack of initial fever. CONCLUSIONS: Using quality improvement methodology, we successfully implemented a sepsis identification pathway on our pediatric unit. The pathway provided a standardized process to identify and evaluate children with possible sepsis requiring timely evaluation and treatment.

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.