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The year 2020 was unlike any in recent history, particularly for those working in health care. With the onset of the SARs-CoV-2 pandemic, many physicians were met with increasing clinical demands, and hospitalists served an instrumental role in providing medical care as the world faced an unprecedented need for health care resources.
In addition, 2020 was a year in which many of us reflected on inequities both inside and outside of medicine. Many in health care witnessed the disproportionate burden that the SARs-CoV-2 pandemic placed on communities of color and inequities pertaining to vaccine distribution.
In spite of the challenges of 2020, the field of pediatric hospital medicine (PHM) has continued to grow and evolve, with an incredible amount of new literature published in 2020.
In this article, we identify the top 10 articles published in 2020, 5 of which are summarized below. These articles were presented at the Pediatric Update at SHM Converge 2021.
The top 5 articles
Association between parent comfort with English and adverse events among hospitalized children
Khan A et al. JAMA Pediatrics. December 2020.1
Background: Hospitalized children experience similar rates of medical errors compared to adult patients, but higher rates in areas that could cause harm.1 A major contributor to medical errors is communication failure, which language barriers frequently contribute to. Single-center data suggest that pediatric patients of families with limited comfort with English experience increased adverse events,2 but multicenter data are lacking.
Findings: This prospective cohort study observed adverse event rates among 2,148 patients from seven teaching hospitals from December 2014 to January 2017. Survey data revealed 147 of 1,666 (9%) parents of patient families expressed limited comfort in English, and Spanish was the predominant language in this group (71%). There were 217 adverse events reported, 142 (65%) of which were deemed preventable by study personnel. Nearly twice as many children of parents with limited comfort with English experienced an adverse event when compared to their English-speaking counterparts (26 of 147 [17.7%] vs. 146 of 1,519 [9.6%]; adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.7). Interpreter use was not measured.
Impact to practice: Children of parents with limited comfort with English are nearly twice as likely to experience adverse events when hospitalized. Hospitals should reflect on current practice and make efforts to improve their ability to identify and communicate with this vulnerable cohort.
Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children
Yeung F et al. Hospital Pediatrics. December 2020.3
Background: Peripheral intravenous catheter (PIV) insertion is performed on most hospitalized children. Unfortunately, PIVs frequently fail and need to be replaced. There is a widespread perception that infusing a crystalloid solution at a low rate through a PIV, a strategy known as “to keep vein open” (TKO) prolongs the patency of PIVs, however there is a lack of evidence to support this practice.4Findings: In this prospective, time-allocated study, 172 children were allocated to either a TKO strategy or a saline-lock strategy with a primary outcome of duration of PIV patency.3 Secondary outcomes included PIV–related complication rates and patient and caregiver satisfaction. The mean duration of PIV patency was 41.68 hours in the TKO group and 44.05 hours in the saline-lock group, which did not meet the prespecified definition of a clinically significant difference. There was no significant difference in prevalence of PIV-associated complications and patient satisfaction was similar between the two groups.
Impact to practice: Running fluid “to keep vein open” does not increase the duration of PIV patency compared to intermittent saline locks. Given that a TKO strategy limits a patient’s mobility, this low-value practice can be discontinued without increasing the risk of PIV failure.
Intensive care unit utilization after adoption of a ward-based high flow nasal cannula protocol
Coon ER et al. Journal of Hospital Medicine. June 2020.5
Background: High Flow Nasal Cannula (HFNC) has been widely adopted for escalation of respiratory support in patients with bronchiolitis; however, its use is dictated by highly variant local protocols.6 Small-scale randomized control trials and systematic reviews show that early HFNC initiation in mild to moderate disease does not change patient outcomes.7Findings: In this retrospective cohort study of ward-based HFNC, the authors used the Pediatric Health Information System database to identify 12 hospitals that had adopted ward-based HFNC protocols. The study used an interrupted time series analysis to compare outcomes for patients ages 3-24 months hospitalized with bronchiolitis (n = 32,809) in the three seasons before and after protocol adoption. Ward-based HFNC adoption paradoxically increased ICU admission (absolute increase 3.1%, 95% confidence interval, 2.8-3.4%) and ICU length of stay (absolute difference 9.1 days/100 patients, 95% CI, 5.1-13.2). Total length of stay and rates of mechanical ventilation were similar between groups.5Impact to practice: Ward-based HFNC protocols are associated with increased ICU utilization. As bronchiolitis is the leading diagnosis in pediatrics, pediatric hospitals can lead ward-based quality efforts to decrease HFNC overutilization focused on decreased initiation or deimplementation.
Lower versus traditional treatment threshold for neonatal hypoglycemia
Van Kempen AAMW et al. New England Journal of Medicine. February 2020.8
Background: Hypoglycemia is the most common metabolic abnormality in newborns, and up to 30% of newborns are routinely monitored for hypoglycemia. There is no consensus regarding the appropriate threshold at which hypoglycemia should be treated in order to prevent neurologic injury. Prior studies of neonatal hypoglycemia have largely been observation and have yielded conflicting results.8Findings: In this multicenter, randomized, noninferiority trial, 689 infants born at 35 weeks gestational age or later with risk factors for hypoglycemia and a measured blood glucose of 36-46 mg/dL were randomized to either a lower glucose treatment threshold (36 mg/dL) or traditional glucose treatment threshold (47 mg/dL). The primary outcome was psychomotor development at 18 months, assessed via the Bayley Scale of Infant and Toddler Development, third edition. There was no significant difference in cognitive or motor scores at 18 months. The lower treatment threshold group had a higher frequency of severe hypoglycemia (< 36 mg/dL) and were more likely to have four or more episodes of hypoglycemia. The traditional treatment threshold group had more supplemental feeding and more IV glucose administration. Length of stay for the mother and baby did not differ between groups.8
Impact to practice: This prospective, randomized study suggests that reducing the treatment threshold for neonatal hypoglycemia did not affect neurodevelopmental at 18 months of age. In contrast, a recent meta-analysis by Shah et al. suggested that neonatal hypoglycemia was not associated with adverse neurodevelopmental outcomes in early childhood; however, differences in rates of neurodevelopmental impairment, low literacy, and low numeracy were detectable by age five.9
Factors associated with family experience in pediatric inpatient care
Feng JY et al. Pediatrics. March 2020 Mar.10
Background: Positive patient experience is associated with better health care outcomes and reduced health care use.11 Consequently, patient experience surveys have played a larger role in public reporting, financial risk sharing arrangements, and pay for performance programs. While adult studies have examined the importance of specific care dimensions for patient experience, data are lacking for inpatient pediatric populations.
Findings: A retrospective study collected Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys from 17,727 patients in 69 hospitals within the United States over a 14-month period.10 Of the 10 care dimensions analyzed, child comfort (aOR 1.50; 95% CI, 1.41-1.60) and nurse-parent communication (aOR 1.50; 95% CI, 1.42-1.58) were most strongly associated with a family’s willingness to recommend a hospital. Additional associated indices included preparing to leave the hospital (aOR 1.34; 95% CI, 1.27-1.41), doctor-parent communication (aOR 1.28; 95% CI, 1.21–1.35), and keeping parents informed (aOR 1.25; 95% CI, 1.18-1.33). Privacy and quietness, which are associated with positive patient experience in adult studies, were not significantly associated with willingness to recommend in this cohort.
Impact to practice: Hospitals seeking to improve patient experience will benefit most by focusing on improving patient comfort and nurse-parent communication. Factors that increase adult patient satisfaction may not be as important to the pediatric population and their families.
The other five articles that comprised the top 10 are listed below:
Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis
Coon ER et al. JAMA Pediatrics. September 2020.12
Clinical prediction rule for distinguishing bacterial from aseptic meningitis
Mintegi S et al. Pediatrics. September 2020.13
The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC Ullman AJ et al. Pediatrics. June 2020.14
A structured neonatal parenting elective: An approach for parenting leave during residency
Cree-Green M et al. Academic Pediatrics. Aug 2020.15
The KidzMed project: Teaching children to swallow tablet medication
Tse Y et al. Archives of Disease in Childhood. November 2020.16
Dr. Steed is an internal medicine and pediatrics hospitalist at Northwestern Memorial Hospital and Ann and Robert H. Lurie’s Children’s Hospital of Chicago. Dr. Fisher is a current fellow in hospice and palliative medicine and a clinical assistant professor at Michigan State University. Dr. Money is an assistant professor of pediatrics at the University of Utah and a fellowship-trained pediatric hospitalist at Utah Valley Hospital and Primary Children’s Hospital.
References
1. Khan A et al. Association between parent comfort with english and adverse events among hospitalized children. JAMA Pediatr. 2020 Dec 1;174(12):e203215. doi: 10.1001/jamapediatrics.2020.3215.
2. Wasserman M et al. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual. May-Jun 2014;36(3):5-16. doi: 10.1111/jhq.12065.
3. Yeung F et al. Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children. Hosp Pediatr. 2020 Dec;10(12):1038-43. doi: 10.1542/hpeds.2020-0137.
4. Mok E et al. A randomized controlled trial for maintaining peripheral intravenous lock in children. Int J Nurs Pract. 2007 Feb;13(1):33-45. doi: 10.1111/j.1440-172X.2006.00607.x.
5. Coon ER et al. Intensive care unit utilization after adoption of a ward-based high-flow nasal cannula protocol. J Hosp Med. 2020 Jun;15(6):325-30. doi: 10.12788/jhm.3417.
6. Kalburgi S and Halley T. High-flow nasal cannula use outside of the ICU setting. Pediatrics. 2020;146(5):e20194083. doi: 10.1542/peds.2019-4083.
7. Leyenaar JK and Ralston SL. Widespread adoption of low-value therapy: The case of bronchiolitis and high-flow oxygen. Pediatrics. 2020 Nov;146(5):e2020021188. doi: 10.1542/peds.2020-021188.
8. Van Kempen AAMW et al. Lower versus traditional treatment threshold for neonatal hypoglycemia. N Engl J Med. 2020 Feb 6;382(6):534-44. doi: 10.1056/NEJMoa1905593.
9. Shah R et al. Neonatal glycaemia and neurodevelopmental outcomes: A systematic review and meta-analysis. Neonatology. 2019;115(2):116-26. doi: 10.1159/000492859.
10. Feng JY et al. Factors associated with family experience in pediatric inpatient care. Pediatrics. 2020 Mar;145(3):e20191264. doi: 10.1542/peds.2019-1264.
11. Anhang Price R et al. Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev. 2014 Oct;71(5):522-54. doi: 10.1177/1077558714541480.
12. Coon ER et al. Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis: The Bronchiolitis Follow-up Intervention Trial (BeneFIT) randomized clinical trial. JAMA Pediatr. 2020 Sep 1;174(9):e201937. doi: 10.1001/jamapediatrics.2020.1937.
13. Mintegi S et al. Clinical prediction rule for distinguishing bacterial from aseptic meningitis. Pediatrics. 2020 Sept;146(3): e20201126. doi: 10.1542/peds.2020-1126.
14. Ullman AJ et al. The Michigan Appropriateness Guide for Intravenous Catheters in pediatrics: miniMAGIC. Pediatrics. 2020 Jun;145(Suppl 3):S269-S284. doi: 10.1542/peds.2019-3474I.
15. Cree-Green M et al. A structured neonatal parenting elective: an approach for parenting leave during residency. Acad Pediatr. 2021 Jan-Feb;21(1):16-18. doi: 10.1016/j.acap.2020.02.008.
16. Tse Y et al. The KidzMed project: Teaching children to swallow tablet medication. Arch Dis Child. 2020 Nov;105(11):1105-7. doi: 10.1136/archdischild-2019-317512.
The year 2020 was unlike any in recent history, particularly for those working in health care. With the onset of the SARs-CoV-2 pandemic, many physicians were met with increasing clinical demands, and hospitalists served an instrumental role in providing medical care as the world faced an unprecedented need for health care resources.
In addition, 2020 was a year in which many of us reflected on inequities both inside and outside of medicine. Many in health care witnessed the disproportionate burden that the SARs-CoV-2 pandemic placed on communities of color and inequities pertaining to vaccine distribution.
In spite of the challenges of 2020, the field of pediatric hospital medicine (PHM) has continued to grow and evolve, with an incredible amount of new literature published in 2020.
In this article, we identify the top 10 articles published in 2020, 5 of which are summarized below. These articles were presented at the Pediatric Update at SHM Converge 2021.
The top 5 articles
Association between parent comfort with English and adverse events among hospitalized children
Khan A et al. JAMA Pediatrics. December 2020.1
Background: Hospitalized children experience similar rates of medical errors compared to adult patients, but higher rates in areas that could cause harm.1 A major contributor to medical errors is communication failure, which language barriers frequently contribute to. Single-center data suggest that pediatric patients of families with limited comfort with English experience increased adverse events,2 but multicenter data are lacking.
Findings: This prospective cohort study observed adverse event rates among 2,148 patients from seven teaching hospitals from December 2014 to January 2017. Survey data revealed 147 of 1,666 (9%) parents of patient families expressed limited comfort in English, and Spanish was the predominant language in this group (71%). There were 217 adverse events reported, 142 (65%) of which were deemed preventable by study personnel. Nearly twice as many children of parents with limited comfort with English experienced an adverse event when compared to their English-speaking counterparts (26 of 147 [17.7%] vs. 146 of 1,519 [9.6%]; adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.7). Interpreter use was not measured.
Impact to practice: Children of parents with limited comfort with English are nearly twice as likely to experience adverse events when hospitalized. Hospitals should reflect on current practice and make efforts to improve their ability to identify and communicate with this vulnerable cohort.
Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children
Yeung F et al. Hospital Pediatrics. December 2020.3
Background: Peripheral intravenous catheter (PIV) insertion is performed on most hospitalized children. Unfortunately, PIVs frequently fail and need to be replaced. There is a widespread perception that infusing a crystalloid solution at a low rate through a PIV, a strategy known as “to keep vein open” (TKO) prolongs the patency of PIVs, however there is a lack of evidence to support this practice.4Findings: In this prospective, time-allocated study, 172 children were allocated to either a TKO strategy or a saline-lock strategy with a primary outcome of duration of PIV patency.3 Secondary outcomes included PIV–related complication rates and patient and caregiver satisfaction. The mean duration of PIV patency was 41.68 hours in the TKO group and 44.05 hours in the saline-lock group, which did not meet the prespecified definition of a clinically significant difference. There was no significant difference in prevalence of PIV-associated complications and patient satisfaction was similar between the two groups.
Impact to practice: Running fluid “to keep vein open” does not increase the duration of PIV patency compared to intermittent saline locks. Given that a TKO strategy limits a patient’s mobility, this low-value practice can be discontinued without increasing the risk of PIV failure.
Intensive care unit utilization after adoption of a ward-based high flow nasal cannula protocol
Coon ER et al. Journal of Hospital Medicine. June 2020.5
Background: High Flow Nasal Cannula (HFNC) has been widely adopted for escalation of respiratory support in patients with bronchiolitis; however, its use is dictated by highly variant local protocols.6 Small-scale randomized control trials and systematic reviews show that early HFNC initiation in mild to moderate disease does not change patient outcomes.7Findings: In this retrospective cohort study of ward-based HFNC, the authors used the Pediatric Health Information System database to identify 12 hospitals that had adopted ward-based HFNC protocols. The study used an interrupted time series analysis to compare outcomes for patients ages 3-24 months hospitalized with bronchiolitis (n = 32,809) in the three seasons before and after protocol adoption. Ward-based HFNC adoption paradoxically increased ICU admission (absolute increase 3.1%, 95% confidence interval, 2.8-3.4%) and ICU length of stay (absolute difference 9.1 days/100 patients, 95% CI, 5.1-13.2). Total length of stay and rates of mechanical ventilation were similar between groups.5Impact to practice: Ward-based HFNC protocols are associated with increased ICU utilization. As bronchiolitis is the leading diagnosis in pediatrics, pediatric hospitals can lead ward-based quality efforts to decrease HFNC overutilization focused on decreased initiation or deimplementation.
Lower versus traditional treatment threshold for neonatal hypoglycemia
Van Kempen AAMW et al. New England Journal of Medicine. February 2020.8
Background: Hypoglycemia is the most common metabolic abnormality in newborns, and up to 30% of newborns are routinely monitored for hypoglycemia. There is no consensus regarding the appropriate threshold at which hypoglycemia should be treated in order to prevent neurologic injury. Prior studies of neonatal hypoglycemia have largely been observation and have yielded conflicting results.8Findings: In this multicenter, randomized, noninferiority trial, 689 infants born at 35 weeks gestational age or later with risk factors for hypoglycemia and a measured blood glucose of 36-46 mg/dL were randomized to either a lower glucose treatment threshold (36 mg/dL) or traditional glucose treatment threshold (47 mg/dL). The primary outcome was psychomotor development at 18 months, assessed via the Bayley Scale of Infant and Toddler Development, third edition. There was no significant difference in cognitive or motor scores at 18 months. The lower treatment threshold group had a higher frequency of severe hypoglycemia (< 36 mg/dL) and were more likely to have four or more episodes of hypoglycemia. The traditional treatment threshold group had more supplemental feeding and more IV glucose administration. Length of stay for the mother and baby did not differ between groups.8
Impact to practice: This prospective, randomized study suggests that reducing the treatment threshold for neonatal hypoglycemia did not affect neurodevelopmental at 18 months of age. In contrast, a recent meta-analysis by Shah et al. suggested that neonatal hypoglycemia was not associated with adverse neurodevelopmental outcomes in early childhood; however, differences in rates of neurodevelopmental impairment, low literacy, and low numeracy were detectable by age five.9
Factors associated with family experience in pediatric inpatient care
Feng JY et al. Pediatrics. March 2020 Mar.10
Background: Positive patient experience is associated with better health care outcomes and reduced health care use.11 Consequently, patient experience surveys have played a larger role in public reporting, financial risk sharing arrangements, and pay for performance programs. While adult studies have examined the importance of specific care dimensions for patient experience, data are lacking for inpatient pediatric populations.
Findings: A retrospective study collected Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys from 17,727 patients in 69 hospitals within the United States over a 14-month period.10 Of the 10 care dimensions analyzed, child comfort (aOR 1.50; 95% CI, 1.41-1.60) and nurse-parent communication (aOR 1.50; 95% CI, 1.42-1.58) were most strongly associated with a family’s willingness to recommend a hospital. Additional associated indices included preparing to leave the hospital (aOR 1.34; 95% CI, 1.27-1.41), doctor-parent communication (aOR 1.28; 95% CI, 1.21–1.35), and keeping parents informed (aOR 1.25; 95% CI, 1.18-1.33). Privacy and quietness, which are associated with positive patient experience in adult studies, were not significantly associated with willingness to recommend in this cohort.
Impact to practice: Hospitals seeking to improve patient experience will benefit most by focusing on improving patient comfort and nurse-parent communication. Factors that increase adult patient satisfaction may not be as important to the pediatric population and their families.
The other five articles that comprised the top 10 are listed below:
Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis
Coon ER et al. JAMA Pediatrics. September 2020.12
Clinical prediction rule for distinguishing bacterial from aseptic meningitis
Mintegi S et al. Pediatrics. September 2020.13
The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC Ullman AJ et al. Pediatrics. June 2020.14
A structured neonatal parenting elective: An approach for parenting leave during residency
Cree-Green M et al. Academic Pediatrics. Aug 2020.15
The KidzMed project: Teaching children to swallow tablet medication
Tse Y et al. Archives of Disease in Childhood. November 2020.16
Dr. Steed is an internal medicine and pediatrics hospitalist at Northwestern Memorial Hospital and Ann and Robert H. Lurie’s Children’s Hospital of Chicago. Dr. Fisher is a current fellow in hospice and palliative medicine and a clinical assistant professor at Michigan State University. Dr. Money is an assistant professor of pediatrics at the University of Utah and a fellowship-trained pediatric hospitalist at Utah Valley Hospital and Primary Children’s Hospital.
References
1. Khan A et al. Association between parent comfort with english and adverse events among hospitalized children. JAMA Pediatr. 2020 Dec 1;174(12):e203215. doi: 10.1001/jamapediatrics.2020.3215.
2. Wasserman M et al. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual. May-Jun 2014;36(3):5-16. doi: 10.1111/jhq.12065.
3. Yeung F et al. Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children. Hosp Pediatr. 2020 Dec;10(12):1038-43. doi: 10.1542/hpeds.2020-0137.
4. Mok E et al. A randomized controlled trial for maintaining peripheral intravenous lock in children. Int J Nurs Pract. 2007 Feb;13(1):33-45. doi: 10.1111/j.1440-172X.2006.00607.x.
5. Coon ER et al. Intensive care unit utilization after adoption of a ward-based high-flow nasal cannula protocol. J Hosp Med. 2020 Jun;15(6):325-30. doi: 10.12788/jhm.3417.
6. Kalburgi S and Halley T. High-flow nasal cannula use outside of the ICU setting. Pediatrics. 2020;146(5):e20194083. doi: 10.1542/peds.2019-4083.
7. Leyenaar JK and Ralston SL. Widespread adoption of low-value therapy: The case of bronchiolitis and high-flow oxygen. Pediatrics. 2020 Nov;146(5):e2020021188. doi: 10.1542/peds.2020-021188.
8. Van Kempen AAMW et al. Lower versus traditional treatment threshold for neonatal hypoglycemia. N Engl J Med. 2020 Feb 6;382(6):534-44. doi: 10.1056/NEJMoa1905593.
9. Shah R et al. Neonatal glycaemia and neurodevelopmental outcomes: A systematic review and meta-analysis. Neonatology. 2019;115(2):116-26. doi: 10.1159/000492859.
10. Feng JY et al. Factors associated with family experience in pediatric inpatient care. Pediatrics. 2020 Mar;145(3):e20191264. doi: 10.1542/peds.2019-1264.
11. Anhang Price R et al. Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev. 2014 Oct;71(5):522-54. doi: 10.1177/1077558714541480.
12. Coon ER et al. Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis: The Bronchiolitis Follow-up Intervention Trial (BeneFIT) randomized clinical trial. JAMA Pediatr. 2020 Sep 1;174(9):e201937. doi: 10.1001/jamapediatrics.2020.1937.
13. Mintegi S et al. Clinical prediction rule for distinguishing bacterial from aseptic meningitis. Pediatrics. 2020 Sept;146(3): e20201126. doi: 10.1542/peds.2020-1126.
14. Ullman AJ et al. The Michigan Appropriateness Guide for Intravenous Catheters in pediatrics: miniMAGIC. Pediatrics. 2020 Jun;145(Suppl 3):S269-S284. doi: 10.1542/peds.2019-3474I.
15. Cree-Green M et al. A structured neonatal parenting elective: an approach for parenting leave during residency. Acad Pediatr. 2021 Jan-Feb;21(1):16-18. doi: 10.1016/j.acap.2020.02.008.
16. Tse Y et al. The KidzMed project: Teaching children to swallow tablet medication. Arch Dis Child. 2020 Nov;105(11):1105-7. doi: 10.1136/archdischild-2019-317512.
The year 2020 was unlike any in recent history, particularly for those working in health care. With the onset of the SARs-CoV-2 pandemic, many physicians were met with increasing clinical demands, and hospitalists served an instrumental role in providing medical care as the world faced an unprecedented need for health care resources.
In addition, 2020 was a year in which many of us reflected on inequities both inside and outside of medicine. Many in health care witnessed the disproportionate burden that the SARs-CoV-2 pandemic placed on communities of color and inequities pertaining to vaccine distribution.
In spite of the challenges of 2020, the field of pediatric hospital medicine (PHM) has continued to grow and evolve, with an incredible amount of new literature published in 2020.
In this article, we identify the top 10 articles published in 2020, 5 of which are summarized below. These articles were presented at the Pediatric Update at SHM Converge 2021.
The top 5 articles
Association between parent comfort with English and adverse events among hospitalized children
Khan A et al. JAMA Pediatrics. December 2020.1
Background: Hospitalized children experience similar rates of medical errors compared to adult patients, but higher rates in areas that could cause harm.1 A major contributor to medical errors is communication failure, which language barriers frequently contribute to. Single-center data suggest that pediatric patients of families with limited comfort with English experience increased adverse events,2 but multicenter data are lacking.
Findings: This prospective cohort study observed adverse event rates among 2,148 patients from seven teaching hospitals from December 2014 to January 2017. Survey data revealed 147 of 1,666 (9%) parents of patient families expressed limited comfort in English, and Spanish was the predominant language in this group (71%). There were 217 adverse events reported, 142 (65%) of which were deemed preventable by study personnel. Nearly twice as many children of parents with limited comfort with English experienced an adverse event when compared to their English-speaking counterparts (26 of 147 [17.7%] vs. 146 of 1,519 [9.6%]; adjusted odds ratio, 2.1; 95% confidence interval, 1.2-3.7). Interpreter use was not measured.
Impact to practice: Children of parents with limited comfort with English are nearly twice as likely to experience adverse events when hospitalized. Hospitals should reflect on current practice and make efforts to improve their ability to identify and communicate with this vulnerable cohort.
Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children
Yeung F et al. Hospital Pediatrics. December 2020.3
Background: Peripheral intravenous catheter (PIV) insertion is performed on most hospitalized children. Unfortunately, PIVs frequently fail and need to be replaced. There is a widespread perception that infusing a crystalloid solution at a low rate through a PIV, a strategy known as “to keep vein open” (TKO) prolongs the patency of PIVs, however there is a lack of evidence to support this practice.4Findings: In this prospective, time-allocated study, 172 children were allocated to either a TKO strategy or a saline-lock strategy with a primary outcome of duration of PIV patency.3 Secondary outcomes included PIV–related complication rates and patient and caregiver satisfaction. The mean duration of PIV patency was 41.68 hours in the TKO group and 44.05 hours in the saline-lock group, which did not meet the prespecified definition of a clinically significant difference. There was no significant difference in prevalence of PIV-associated complications and patient satisfaction was similar between the two groups.
Impact to practice: Running fluid “to keep vein open” does not increase the duration of PIV patency compared to intermittent saline locks. Given that a TKO strategy limits a patient’s mobility, this low-value practice can be discontinued without increasing the risk of PIV failure.
Intensive care unit utilization after adoption of a ward-based high flow nasal cannula protocol
Coon ER et al. Journal of Hospital Medicine. June 2020.5
Background: High Flow Nasal Cannula (HFNC) has been widely adopted for escalation of respiratory support in patients with bronchiolitis; however, its use is dictated by highly variant local protocols.6 Small-scale randomized control trials and systematic reviews show that early HFNC initiation in mild to moderate disease does not change patient outcomes.7Findings: In this retrospective cohort study of ward-based HFNC, the authors used the Pediatric Health Information System database to identify 12 hospitals that had adopted ward-based HFNC protocols. The study used an interrupted time series analysis to compare outcomes for patients ages 3-24 months hospitalized with bronchiolitis (n = 32,809) in the three seasons before and after protocol adoption. Ward-based HFNC adoption paradoxically increased ICU admission (absolute increase 3.1%, 95% confidence interval, 2.8-3.4%) and ICU length of stay (absolute difference 9.1 days/100 patients, 95% CI, 5.1-13.2). Total length of stay and rates of mechanical ventilation were similar between groups.5Impact to practice: Ward-based HFNC protocols are associated with increased ICU utilization. As bronchiolitis is the leading diagnosis in pediatrics, pediatric hospitals can lead ward-based quality efforts to decrease HFNC overutilization focused on decreased initiation or deimplementation.
Lower versus traditional treatment threshold for neonatal hypoglycemia
Van Kempen AAMW et al. New England Journal of Medicine. February 2020.8
Background: Hypoglycemia is the most common metabolic abnormality in newborns, and up to 30% of newborns are routinely monitored for hypoglycemia. There is no consensus regarding the appropriate threshold at which hypoglycemia should be treated in order to prevent neurologic injury. Prior studies of neonatal hypoglycemia have largely been observation and have yielded conflicting results.8Findings: In this multicenter, randomized, noninferiority trial, 689 infants born at 35 weeks gestational age or later with risk factors for hypoglycemia and a measured blood glucose of 36-46 mg/dL were randomized to either a lower glucose treatment threshold (36 mg/dL) or traditional glucose treatment threshold (47 mg/dL). The primary outcome was psychomotor development at 18 months, assessed via the Bayley Scale of Infant and Toddler Development, third edition. There was no significant difference in cognitive or motor scores at 18 months. The lower treatment threshold group had a higher frequency of severe hypoglycemia (< 36 mg/dL) and were more likely to have four or more episodes of hypoglycemia. The traditional treatment threshold group had more supplemental feeding and more IV glucose administration. Length of stay for the mother and baby did not differ between groups.8
Impact to practice: This prospective, randomized study suggests that reducing the treatment threshold for neonatal hypoglycemia did not affect neurodevelopmental at 18 months of age. In contrast, a recent meta-analysis by Shah et al. suggested that neonatal hypoglycemia was not associated with adverse neurodevelopmental outcomes in early childhood; however, differences in rates of neurodevelopmental impairment, low literacy, and low numeracy were detectable by age five.9
Factors associated with family experience in pediatric inpatient care
Feng JY et al. Pediatrics. March 2020 Mar.10
Background: Positive patient experience is associated with better health care outcomes and reduced health care use.11 Consequently, patient experience surveys have played a larger role in public reporting, financial risk sharing arrangements, and pay for performance programs. While adult studies have examined the importance of specific care dimensions for patient experience, data are lacking for inpatient pediatric populations.
Findings: A retrospective study collected Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys from 17,727 patients in 69 hospitals within the United States over a 14-month period.10 Of the 10 care dimensions analyzed, child comfort (aOR 1.50; 95% CI, 1.41-1.60) and nurse-parent communication (aOR 1.50; 95% CI, 1.42-1.58) were most strongly associated with a family’s willingness to recommend a hospital. Additional associated indices included preparing to leave the hospital (aOR 1.34; 95% CI, 1.27-1.41), doctor-parent communication (aOR 1.28; 95% CI, 1.21–1.35), and keeping parents informed (aOR 1.25; 95% CI, 1.18-1.33). Privacy and quietness, which are associated with positive patient experience in adult studies, were not significantly associated with willingness to recommend in this cohort.
Impact to practice: Hospitals seeking to improve patient experience will benefit most by focusing on improving patient comfort and nurse-parent communication. Factors that increase adult patient satisfaction may not be as important to the pediatric population and their families.
The other five articles that comprised the top 10 are listed below:
Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis
Coon ER et al. JAMA Pediatrics. September 2020.12
Clinical prediction rule for distinguishing bacterial from aseptic meningitis
Mintegi S et al. Pediatrics. September 2020.13
The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC Ullman AJ et al. Pediatrics. June 2020.14
A structured neonatal parenting elective: An approach for parenting leave during residency
Cree-Green M et al. Academic Pediatrics. Aug 2020.15
The KidzMed project: Teaching children to swallow tablet medication
Tse Y et al. Archives of Disease in Childhood. November 2020.16
Dr. Steed is an internal medicine and pediatrics hospitalist at Northwestern Memorial Hospital and Ann and Robert H. Lurie’s Children’s Hospital of Chicago. Dr. Fisher is a current fellow in hospice and palliative medicine and a clinical assistant professor at Michigan State University. Dr. Money is an assistant professor of pediatrics at the University of Utah and a fellowship-trained pediatric hospitalist at Utah Valley Hospital and Primary Children’s Hospital.
References
1. Khan A et al. Association between parent comfort with english and adverse events among hospitalized children. JAMA Pediatr. 2020 Dec 1;174(12):e203215. doi: 10.1001/jamapediatrics.2020.3215.
2. Wasserman M et al. Identifying and preventing medical errors in patients with limited English proficiency: Key findings and tools for the field. J Healthc Qual. May-Jun 2014;36(3):5-16. doi: 10.1111/jhq.12065.
3. Yeung F et al. Saline-lock versus continuous infusion: Maintaining peripheral intravenous catheter access in children. Hosp Pediatr. 2020 Dec;10(12):1038-43. doi: 10.1542/hpeds.2020-0137.
4. Mok E et al. A randomized controlled trial for maintaining peripheral intravenous lock in children. Int J Nurs Pract. 2007 Feb;13(1):33-45. doi: 10.1111/j.1440-172X.2006.00607.x.
5. Coon ER et al. Intensive care unit utilization after adoption of a ward-based high-flow nasal cannula protocol. J Hosp Med. 2020 Jun;15(6):325-30. doi: 10.12788/jhm.3417.
6. Kalburgi S and Halley T. High-flow nasal cannula use outside of the ICU setting. Pediatrics. 2020;146(5):e20194083. doi: 10.1542/peds.2019-4083.
7. Leyenaar JK and Ralston SL. Widespread adoption of low-value therapy: The case of bronchiolitis and high-flow oxygen. Pediatrics. 2020 Nov;146(5):e2020021188. doi: 10.1542/peds.2020-021188.
8. Van Kempen AAMW et al. Lower versus traditional treatment threshold for neonatal hypoglycemia. N Engl J Med. 2020 Feb 6;382(6):534-44. doi: 10.1056/NEJMoa1905593.
9. Shah R et al. Neonatal glycaemia and neurodevelopmental outcomes: A systematic review and meta-analysis. Neonatology. 2019;115(2):116-26. doi: 10.1159/000492859.
10. Feng JY et al. Factors associated with family experience in pediatric inpatient care. Pediatrics. 2020 Mar;145(3):e20191264. doi: 10.1542/peds.2019-1264.
11. Anhang Price R et al. Examining the role of patient experience surveys in measuring health care quality. Med Care Res Rev. 2014 Oct;71(5):522-54. doi: 10.1177/1077558714541480.
12. Coon ER et al. Comparison of as-needed and scheduled posthospitalization follow-up for children hospitalized for bronchiolitis: The Bronchiolitis Follow-up Intervention Trial (BeneFIT) randomized clinical trial. JAMA Pediatr. 2020 Sep 1;174(9):e201937. doi: 10.1001/jamapediatrics.2020.1937.
13. Mintegi S et al. Clinical prediction rule for distinguishing bacterial from aseptic meningitis. Pediatrics. 2020 Sept;146(3): e20201126. doi: 10.1542/peds.2020-1126.
14. Ullman AJ et al. The Michigan Appropriateness Guide for Intravenous Catheters in pediatrics: miniMAGIC. Pediatrics. 2020 Jun;145(Suppl 3):S269-S284. doi: 10.1542/peds.2019-3474I.
15. Cree-Green M et al. A structured neonatal parenting elective: an approach for parenting leave during residency. Acad Pediatr. 2021 Jan-Feb;21(1):16-18. doi: 10.1016/j.acap.2020.02.008.
16. Tse Y et al. The KidzMed project: Teaching children to swallow tablet medication. Arch Dis Child. 2020 Nov;105(11):1105-7. doi: 10.1136/archdischild-2019-317512.
