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Tertiary Care Children's Hospital (tertiary + care_children_hospital)
Selected AbstractsAfraid in the hospital: Parental concern for errors during a child's hospitalization,,§JOURNAL OF HOSPITAL MEDICINE, Issue 9 2009Beth A. Tarini MD Abstract OBJECTIVE: (1) To determine the proportion of parents concerned about medical errors during a child's hospitalization; and (2) the association between this concern and parental self-efficacy with physician interactions. STUDY DESIGN: Cross-sectional survey. SETTING: Tertiary care children's hospital. PARTICIPANTS: Parents of children admitted to the general medical service. OUTCOME MEASURE: Parental concern about medical errors. METHODS: Parents were asked their agreement with the statement "When my child is in the hospital I feel that I have to watch over the care that he/she is receiving to make sure that mistakes aren't made." We used multivariate logistic regression to examine the association between parents' self-efficacy with physician interactions and the need "to watch over a child's care," adjusting for parent and child demographics, English proficiency, past hospitalization, and social desirability bias. RESULTS: Of 278 eligible parents, 130 completed surveys and 63% reported the need to watch over their child's care to ensure that mistakes were not made. Parents with greater self-efficacy with physician interactions were less likely to report this need (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.72-0.92). All parents who were "very uncomfortable" communicating with doctors in English reported the need to watch over their child's care to prevent mistakes. CONCLUSIONS: Nearly two-thirds of surveyed parents felt the need to watch over their child's hospital care to prevent mistakes. Parents with greater self-efficacy with physician interactions were less likely to report the need to watch over their child's care while parents with lower English proficiency were more likely to report this need. Journal of Hospital Medicine 2009;4:521,527. © 2009 Society of Hospital Medicine. [source] Safety on an inpatient pediatric otolaryngology service: Many small errors, few adverse eventsTHE LARYNGOSCOPE, Issue 5 2009Rahul K. Shah MD Abstract Objectives: Studies of medical error demonstrate that errors and adverse events (AEs) are common in hospitals. There are little data of errors on pediatric surgical services. Methods: We retrospectively reviewed 50 randomly selected inpatient admissions to the otolaryngology service at a tertiary care children's hospital. We used a "zero-defect" paradigm, recording any error or adverse event,from minor errors such as illegible notes to more significant errors such as mismanagement resulting in a bleeding emergency. Results: A total of 553 errors/AEs were identified in 50 admissions. Most (449) were charting or record-keeping deficiencies. Minor AEs (n = 26) and moderate AEs (n = 8) were present in 38% of admissions; there were no major AEs or permanent morbidity. Medication-related errors occurred in 22% of admissions, but only two resulted in minor AEs. There was a positive correlation between minor errors and AEs; however, this was not statistically significant. Conclusions: Multiple errors occurred in every inpatient pediatric otolaryngology admission; however, only 26 minor and eight moderate AEs were identified. The rate of errors per 1,000 hospital days (6,356 per 1,000 days) is higher than previously reported in voluntary reporting studies, possibly due to our methodology of physician review with a "zero-defect" standard. Trends in the data suggest that the presence of small errors may be associated with the risk of adverse events. Although labor-intensive, physician chart review is a valuable tool for identifying areas for improvement. Although small errors were common, there were few harms and no major morbidity. Laryngoscope, 2009 [source] Development and Maturation of the Pediatric Human Vocal Fold Lamina Propria,THE LARYNGOSCOPE, Issue 1 2005Christopher J. Hartnick MD Abstract Objective: To identify characteristic patterns of maturation of the human vocal fold lamina propria as it develops into a mature structure. Methods: Histologic evaluation of sectioned true vocal folds from 34 archived larynges ages 0 to 18 years using hematoxylin-eosin, trichrome, Alcian blue pH 2.5, Weigert reticular, and Miller's elastin stain. Location: Pathology department at a tertiary care children's hospital. Results: At birth and shortly thereafter, there exists a relative hypercellular monolayer of cells throughout the lamina propria. By 2 months of age, there are the first signs of differentiation into a bilaminar structure of distinct cellular population densities. Between 11 months and 5 years, two distinct patterns are seen: 1) this bilaminar structure and 2) a lamina propria where there exists a third more hypocellular region immediately adjacent to the vocalis muscle (this region is similar to the superficial hypocellular region found just deep to the surface epithelium). By 7 years of age, all of the specimens exhibit this transition between the middle and the deeper layers according to differential density of cell populations. A lamina propria structure defined by differential fiber composition (elastin and collagen fibers) is not present until 13 years of age and then is present throughout adolescence. Conclusions: Using the classic adult model of fiber composition and density to differentiate the layered structure of the lamina propria of the human vocal fold may not adequately allow for a thorough description of the process of maturation and development. Rather, distinct regions of cell density are seen as early as 2 months postpartum, and the model of cellular distribution may serve better to describe the lamina propria as it develops. Cell-signaling processes that shape the formation of the lamina propria appear to produce layered populations of differential cell density that in turn will later produce differential fiber compositions. Early development therefore can be followed by evaluating the maturation of these differing cell populations. Future studies are needed to quantify these cell distribution patterns, to study the cell signaling processes that trigger this maturation, and to correlate these findings with mechanical modeling. [source] Effect of Trainees on Length of Stay in the Pediatric Emergency DepartmentACADEMIC EMERGENCY MEDICINE, Issue 9 2009Catherine James MD Abstract Background:, Emergency departments (EDs) in teaching hospitals have competing goals of timely patient care and supervised trainee education. Previous investigations have indicated that trainees add time to the length of ED patient encounters. However, no studies have quantified the effect of trainees on pediatric ED length of stay (LOS). Objectives:, The objectives were to measure the effect of trainees on pediatric ED LOS by comparing LOS for patients managed by a pediatric emergency physician (PEP) alone to LOS for patients seen by a trainee and a precepting PEP (Trainee+PEP). A secondary objective was to identify factors other than provider type associated with LOS differences observed in teaching hospital pediatric EDs. Methods:, Data were extracted from a computerized ED tracking system in an urban tertiary care children's hospital with approximately 52,000 visits annually. All patients were seen by a PEP alone, an urgent care physician, or a trainee (a pediatric emergency medicine fellow; a pediatric, emergency medicine, or combined internal medicine/pediatrics resident; or a medical student) plus a precepting PEP. The primary comparison was the ratio of median LOS for the PEP group versus the Trainee+PEP group. Results:, There were 92,193 visits eligible for inclusion over a 2-year period. Median patient age was 5.75 years (interquartile range [IQR] = 21 months to 12.9 years). The PEP group managed 9,141 patients (10%), while the Trainee+PEP group treated 72,135 patients (78%). Overall LOS for an ED visit was 221 minutes. The median LOS was 192 minutes for PEP patients and 225 minutes for Trainee+PEP patients (difference of means = 17%, p < 0.001). Laboratory and imaging studies were associated with LOS increases of 111 and 74 minutes, respectively; both were performed more frequently in Trainee+PEP patients (44% vs. 33% for laboratory studies and 41% vs. 39% for imaging studies, both comparisons p < 0.001). When LOS was analyzed after adjusting for confounding factors including patient acuity, laboratory or radiologic testing, and trainee year, LOS for Trainee+PEP was higher by 17 minutes, or 9% (95% confidence interval [CI] = 6% to 12%, p < 0.001). When LOS was examined for four specific diagnoses (asthma, gastroenteritis, appendicitis, foot/ankle sprain), there were no significant differences in LOS between the PEP and Trainee+PEP groups. Conclusions:, In the pediatric ED of a teaching hospital, ED LOS is on average 9% higher in patients seen by trainees. In an era of increasing efforts to accelerate throughput while training future providers, these findings provide an important metric for the delivery of pediatric emergency care. [source] Complete and sustained remission of juvenile dermatomyositis resulting from aggressive treatmentARTHRITIS & RHEUMATISM, Issue 6 2009Susan Kim Objective To assess the time needed to achieve sustained, medication-free remission in a cohort of patients with juvenile dermatomyositis (DM) receiving a stepwise, aggressive treatment protocol. Methods Between 1994 and 2004, a cohort of 49 children with juvenile DM who were followed up at a single tertiary care children's hospital using disease activity measures according to a specific protocol received standardized therapy with steroids and methotrexate. If a patient's strength or muscle enzyme levels did not normalize with this initial therapy, additional medications were added in rapid succession to the treatment regimen. The primary outcome measure was time to complete remission. Additional outcome measures were onset of calcinosis, effect of treatment on height, and complications resulting from medications. Results Forty-nine patients were followed up for a mean ± SD of 48 ± 30 months. All but 1 patient received 2 or more medications simultaneously. Transient localized calcifications occurred in 4 patients (8%), and 2 additional patients (4%) had persistent calcinosis. Despite the aggressive therapy, complications associated with treatment were mild and were primarily attributable to steroids. No persistent effect on longitudinal growth was observed. A complete, medication-free remission was achieved in 28 patients; the median time to achievement of complete remission was 38 months (95% confidence interval 32,44 months). None of these patients experienced a disease flare that required resumption of medications during the subsequent period of observation (mean ± SD 36 ± 19.7 months). Conclusion Our findings suggest that aggressive treatment of juvenile DM aimed at achieving rapid, complete control of muscle weakness and inflammation improves outcomes and reduces disease-related complications. In more than one-half of the children whose disease was treated in this manner (28 of 49), a prolonged, medication-free remission was attained within a median of 38 months from the time of diagnosis. [source] The Anatomic Relationship of Femoral Vein to Femoral Artery in Euvolemic Pediatric Patients by Ultrasonography: Implications for Pediatric Femoral Central Venous AccessACADEMIC EMERGENCY MEDICINE, Issue 5 2008Fred H. Warkentine MD Abstract Background:, Knowledge of the femoral vein (FV) anatomy in pediatric patients is important in the selection of appropriate size central line catheters as well as the approach to central venous access. This knowledge may avoid potential complications during central line access. Objectives:, To describe the relationship of the FV to the femoral artery (FA). To measure FV diameter and FV depth using ultrasonography (US) in newborns, infants, and children up to 9 years of age. Methods:, This study was a prospective descriptive study at a tertiary care children's hospital. A convenience sample of euvolemic children was enrolled aged 0,9 years presenting to an urban pediatric emergency department. All patients underwent a standardized US evaluation using a Sonosite Titan bedside machine by a single emergency physician. The FA and FV were identified by four criteria: relative positions, FV compressibility, FV enlargement by Valsalva maneuver, and absence of FV pulsatility. The position of the FV relative to the FA was described as being completely overlapped by the FA, having partial (<50%) overlap by the FA, and having no overlap by the FA. The FV depth was measured from the skin to the superior border of the vein using the US machine's caliper function. Results:, A total of 84 patients were studied. The FV was found to be completely overlapped by the FA in 8% of subjects and partially overlapped by the FA in 4% of subjects. The mean FV diameter ranged from 4.5 mm in young infants to 10.8 mm in patients 9 years of age. The mean FV depth ranged from 6.5 mm in neonates to 11.2 mm in patients 9 years of age. Conclusions:, External landmarks were not always predictive of internal anatomy. The FV was completely or partially overlapped by the FA in 12% of cases. Thus, visualization of femoral vessels should be recommended prior to attempting pediatric femoral central venous access. [source] Costs of Treating Children With Complicated Pneumonia: A Comparison of Primary Video-Assisted Thoracoscopic Surgery and Chest Tube Placement,PEDIATRIC PULMONOLOGY, Issue 1 2010MSCE, Samir S. Shah MD Abstract Objectives To describe charges associated with primary video-assisted thoracoscopic surgery (VATS) and primary chest tube placement in a multicenter cohort of children with empyema and to determine whether pleural fluid drainage by primary VATS was associated with cost-savings compared with primary chest tube placement. Study Design Retrospective cohort study. Setting and Participants Administrative database containing inpatient resource utilization data from 27 tertiary care children's hospitals. Patients between 12 months and 18 years of age diagnosed with complicated pneumonia were eligible if they were discharged between 2001 and 2005 and underwent early (within 2 days of index hospitalization) pleural fluid drainage. Main Exposure Method of pleural fluid drainage, categorized as VATS or chest tube placement. Results Pleural drainage in the 764 patients was performed by VATS (n,=,50) or chest tube placement (n,=,714). There were 521 (54%) males. Median hospital charges were $36,320 [interquartile range (IQR), $24,814,$62,269]. The median pharmacy and radiologic imaging charges were $5,884 (IQR, $3,142,$11,357) and $2,875 (IQR, $1,703,$4,950), respectively. Adjusting for propensity score matching, patients undergoing primary VATS did not have higher charges than patients undergoing primary chest tube placement. Conclusions In this multicenter study, we found that the charges incurred in caring for children with empyema were substantial. However, primary VATS was not associated with higher total or pharmacy charges than primary chest tube placement, suggesting that the additional costs of performing VATS are offset by reductions in length of stay (LOS) and requirement for additional procedures. Pediatr Pulmonol. 2010; 45:71,77. © 2009 Wiley-Liss, Inc. [source] | ||||||||||