bluuebunny/crossref_metadata_2025_split huggingface dataset:
Knowledge, attitudes, and practices regarding opioid use in the pediatric emergency department
Authors: Fowler Megan , Ali Samina , Gouin Serge , Drendel Amy , Poonai Naveen , Jun Esther , Sivakumar Mithra , Dong Kathryn 
Published: May 2018

Abstract

BACKGROUND
Inadequate pain management in children is ubiquitous in the emergency department (ED). Inadequate pain management in children can have both short and long term detrimental effects. As the current national opioid crisis has highlighted, physicians are caught between balancing pain management and the risk of long term opioid dependence.

OBJECTIVES
This study aimed to describe paediatric emergency physicians’ (PEPs) willingness to prescribe opioids to children in the ED and at discharge, perceived knowledge regarding common fears and myths about opioid use, management approach to hypothetical scenarios of varying musculoskeletal injury (MSK-I) pain in children, and perceived facilitators and barriers to prescribing opioids.

DESIGN/METHODS
A unique survey tool was created using published methodology guidelines. Information regarding practices, knowledge, attitudes, perceived barriers, facilitators and demographics were collected. The survey was distributed to all physician members of Pediatric Emergency Research Canada (PERC), using a modified Dillman’s Tailored Design method, from October to December 2017.

RESULTS
The response rate was 49.7% (124/242); 53% (57/107) were female, mean age was 43.6 years (+/- 8.7), and 58% (72/124) had paediatric emergency subspecialty training. The most common first line pain medication in the ED was ibuprofen for mild, moderate and severe MSK-I related pain (94.4% (117/124), 89.5% (111/124), and 62.9% (78/124), respectively). For moderate and severe MSK-I pain, intranasal fentanyl was the most common opioid for first (35.5% (44/124) and 61.3% (76/124), respectively) and second line pain management (41.1% (51/124) and 20.2% (25/124), respectively). 74.8% (89/119) of PEPs reported that an opioid protocol would be helpful, specifically for morphine, fentanyl, and hydromorphone. Using a 0–100 scale, physicians minimally worried about physical dependence (13.3 +/-19.3), addiction (16.6 +/-19.8), and diversion of opioids (32.8+/-26.4) when prescribing short-term opioids to children. They reported that the current opioid crisis minimally influenced their willingness to prescribe opioids (30.0 +/-26.2). Physicians reported rarely (36%; 45/125) or never (28%; 35/125) completing a screening risk assessment prior to prescribing opioids.

CONCLUSION
Intranasal fentanyl was the top opioid for all MSK-I pain intensities. PEPs are minimally concerned regarding dependence, addiction, and the current opioid crisis when prescribing short-term opioids to children. There is an urgent need for evidence regarding the dependence and addiction risk for children receiving short term opioids in order to create knowledge translation tools for ED physicians. Opioid specific protocols in the ED would likely improve physician comfort in responsible and adequate pain management for children.
IMPLEMENTATION AND EVALUATION OF A DKA ORDER SET IN A PEDIATRIC TERTIARY CARE HOSPITAL: A QUALITY IMPROVEMENT INITIATIVE
Authors: Flood Kayla , Nour Munier , Cattell Vicki , Holt Tayna , Seifert Blair , Rozdilsky Janlyn , Inman Mark 
Published: May 2018

Abstract

BACKGROUND
Diabetic ketoacidosis (DKA) is a common clinical presentation in new and previously diagnosed paediatric patients with type 1 diabetes. In contrast to other Canadian tertiary paediatric hospitals, our center lacked a physician-endorsed evidence-informed care pathway for management of DKA. In the absence of a standardized approach to DKA, variability in patient management and outcomes were observed. This project was a quality improvement initiative that sought to develop and pilot a paediatric DKA order set.

OBJECTIVES
Our primary aim was to attain broad clinical uptake of the order set at our tertiary care center over a 12-month period. Secondary aims included improved standard-of-care DKA management: appropriate fluid bolus volume and maintenance rates; initial potassium management; and timely dextrose supplementation.

DESIGN/METHODS
A paediatric multidisciplinary collaborative was created to examine evidence for the development and implementation of a DKA order set. Implementation of the order set involved department wide education, targeted end-user education, and quarterly end-user review. A modified plan-do-study-act (PDSA) cycle guided by end-user feedback and early clinical outcomes allowed progressive order set modifications.

RESULTS
A retrospective chart review of fifty paediatric patients presenting to our center between April 2014 and September 2016 (pre-implementation) was compared to thirty paediatric patients presenting in DKA during the post-implementation phase (September 2016 – September 2017). There were no statistically significant differences in demographic and clinical characteristics between the groups. We achieved 83% uptake of the order set for patients presenting to our tertiary center and 67% uptake for patients transferred from peripheral centers. Improvements in DKA management included: appropriate intravenous (IV) maintenance fluid rates (20% vs. 48.3%, p=0.008), earlier administration of potassium to IV fluids (66% vs. 93.1%, p=0.006); appropriate potassium chloride dosing (40 mmol/L) to IV fluid (40% vs. 79.3%, p=0.0007) and earlier addition of IV dextrose (67.4% vs. 93.1%, p=0.009). No differences in moderate to severe hypokalemia (< 3.0 mmol/L), hypoglycemia (<4.0 mmol/L) or clinically suspected cerebral edema occurred.

CONCLUSION
Implementation of a DKA order set in a tertiary hospital required identification of key stakeholders, formation of a multidisciplinary team, and the development of an evaluation process. There was an observed increase in physician order set uptake and DKA management practice improvements. Future goals involve expanding the implementation and evaluation process to regional and remote centers and analyzing the impact on resource utilization.
VARIABILITY IN EMERGENT MANAGEMENT OF DIABETIC KETOACIDOSIS IN PEDIATRICS: A RETROSPECTIVE CHART REVIEW
Authors: Thawer Zoyah , Saleh David , Gregoire Keith 
Published: May 2018

Abstract

BACKGROUND
Variability in the management of paediatric diabetic ketoacidosis (DKA) has been well described in the literature. Although there are many paediatric DKA management guidelines available at tertiary care centres, there seems to be a lack of familiarity with these in some community hospitals, leading to management inconsistent with evidence-based clinical practice.

OBJECTIVES
Our objectives were to review the management of paediatric patients who present in DKA, identify those that received initial emergent treatment not consistent with current guidelines, and track associated complications.

DESIGN/METHODS
Forty-seven charts of paediatric patients admitted to our institution (including patients transferred from peripheral hospitals) from January, 2012 to July, 2017 were identified by ICD-10 codes containing “ketoacidosis”. Primary outcome measures for inadequate management included major risk factors for cerebral edema - IV insulin boluses, IV bicarbonate boluses, hypo-osmolar IV fluid administration and non-NPO status - as well as inappropriate IV fluid boluses>10mL/kg, insulin infusion initiated within the first hour after IV fluids were initiated, and inadequate potassium replacement.

RESULTS
At least one area of inadequate management occurred at a rate of 74.5% with no significant difference between community hospitals and our tertiary centre. The most common parameter was inadequate replacement of potassium (44.7%), followed by receiving an IV fluid bolus>10mL/kg (40.4%). Twenty-three percent of patients received inadequate management that included a treatment-related major risk factor for cerebral edema. The most common complication was hypoglycemia (BG<4.0mM; 14.9%) and there were no cases of cerebral edema or patients that received a CT head. Though the mean time to insulin infusion initiation was 4.0 hours at outside centres and 2.8 hours at our tertiary centre, the difference was not statistically significant (p=0.26). However, there was a statistically significant difference in time to correction of acidosis, with correction of DKA happening more quickly at our tertiary centre (9.5h compared to 12.7h at outside centres; p=0.03).

CONCLUSION
Optimal paediatric DKA management continues to be a challenge despite the presence of multiple, evidence-based guidelines. Gradual resuscitation with appropriate fluids appears to be the most common area in which variability exists in community and tertiary care centres.
Use of a daily rounding checklist on the Clinical Teaching Unit improves interdisciplinary communication around discharge
Authors: Remington Michaela , Kong Cynthia 
Published: May 2018

Abstract

BACKGROUND
As the care needs of the paediatric inpatient population become increasingly complex, demands for hospitalization and efficient patient flow have resulted in the need for increased attention to discharge processes. Inefficient discharges impact flow throughout the healthcare system, extend length of stay, increase health care costs and decrease patient satisfaction. As a large inpatient service with high staff turnover, our Clinical Teaching Unit (CTU) experiences considerable variability in approach to discharge planning. Prior work at our institution has recognized inconsistent practice and gaps in communication around discharge planning as challenges to efficient patient discharge.

OBJECTIVES
Using quality improvement (QI) methodology, we aimed to decrease discharge delays on CTU, by implementing a process to identify and document patient specific discharge criteria. By focusing on discharge criteria, we sought to improve communication regarding discharge goals and patient readiness between care members, encouraging early discharge planning.

DESIGN/METHODS
We implemented a standardized CTU rounding checklist for use during daily inpatient rounds. On this checklist, physicians were instructed to document clear, patient-specific discharge criteria. Use of the checklist was encouraged through multiple avenues, including announcements at educational events, real time feedback on use to the front-line care teams and a monthly competition between resident teams. Through Plan-Do-Study-Act (PDSA) cycles, we collected feedback from the multidisciplinary team, and the checklist underwent multiple iterations to optimize use. CTU inpatient rounds were observed weekly and outcome, process and balance measures were collected.

RESULTS
With implementation of the checklist, a cultural shift towards explicit, thoughtful discussion of discharge criteria and planning was observed on daily patient rounds. Identification of patient specific discharge criteria increased from less than 30% to over 90% after implementation of the checklist. The purposeful documentation of discharge criteria received positive nursing feedback, and nursing awareness of discharge goals improved from 20–30% to over 70%. Improvements were sustained over a six-month period.

CONCLUSION
This QI project utilized a daily rounding checklist to engage care teams in purposeful conversations around discharge on rounds. By documenting patient-specific discharge criteria, interdisciplinary communication was improved and bedside nurses felt better informed of discharge goals.
Future project directions include the development of diagnosis specific standardized discharge criteria, exploration of specific discharge barriers, and identification of institution-specific resources that may help alleviate these delays to further improve discharge efficiency.
Improving appropriateness of oxygen saturation monitoring in paediatric patients with acute respiratory illness: a QI initiative
Authors: Parisien Brigitte , Cheng Daryl , Marano Maria , Johnstone Julie , Carmichael Nicole , Al-Maawali Ali , Gamulka Beth 
Published: May 2018

Abstract

BACKGROUND
Oxygen saturation monitoring (OSM) is a key aspect of clinical care in paediatric patients with acute respiratory disease. It is commonplace in the assessment of children with bronchiolitis, asthma and pneumonia and serves as a proxy for illness severity. However, there is a paucity of standardized guidelines around appropriate pulse oximetry and OSM use in these patients. Some preliminary evidence shows that intermittent pulse oximetry is as safe as continuous oximetry monitoring in children with bronchiolitis. Furthermore, inappropriate OSM may lead to overdiagnosis and overtreatment of mild hypoxia with no demonstrable clinical improvement and therefore contribute to prolonged length of stay.

OBJECTIVES
As part of The Choosing Wisely campaign, our aim is to increase the appropriate use of OSM in paediatric inpatients with asthma, bronchiolitis or pneumonia in our center to 90% by April 2018.

DESIGN/METHODS
Appropriate monitoring is defined as intermittent OSM when a patient is off oxygen for &gt;2 hours and continuous OSM whilst the patient is receiving supplemental oxygen. A 4 week pre-intervention baseline chart review showed 62% (23/37) had appropriate OSM. Series of interventions along the hierarchy of effectiveness were then chosen to improve the main outcome measure:
• Educational sessions oriented at medical and nursing staff were provided to guide evidence-based practice and to reinforce the use of specific orders around OSM;
• Visual cues were used in strategic locations to remind medical staff of appropriate OSM and to prompt discussion during ward rounds;
• Weekly reminders and performance updates were displayed and electronically circulated to medical and nursing staff.
Post-intervention data collection occurred via convenience sampling by project leaders from December 2017 to April 2018. A PDSA cycle approach was used to modify interventions.

RESULTS
OSM appropriateness increased to 78% (56/72) in the first 4 weeks post-initial interventions. There were no negative impacts on balancing measures. We anticipate an ongoing graded increase in appropriateness across the study period triggered by collective staff awareness and synergistic interventions.

CONCLUSION
This QI initiative will improve the appropriate use of OSM in patients admitted for bronchiolitis, pneumonia or asthma at our paediatric tertiary hospital without increasing the number of patient safety events or admissions to the intensive care unit. Further interventions are planned to ensure greater uptake and sustainability.
NEONATAL FOLLOW-UP IN CANADA. A NATIONAL SURVEY
Authors: Albaghli Fawaz , Synnes Anne , Girardi Alberta , Church Paige , Ballantyne Marilyn 
Published: May 2018

Abstract

BACKGROUND
The Canadian Neonatal Follow-Up Network (CNFUN) was developed in 2008 to facilitate collaboration in research by providing a national database and implemented standardized neurodevelopmental assessments at 18 and 36 months corrected ages for babies born <29-week gestational age. Previous Canadian surveys showed a large variability in neonatal follow-up practices. This is the first Canadian national survey since the establishment of CNFUN.

OBJECTIVES
To describe the current status of neonatal follow-up services in Canada and to evaluate the impact of CNFUN by comparing the results of the current survey to a 2006 survey. Proportions are compared using chi square, p value < 0.006 adjusted for multiple comparisons.

DESIGN/METHODS
All 26 Level-III University Affiliated Neonatal Follow-up programs in Canada belonged to CNFUN and were invited to participate in this comprehensive online survey. Questions were based on previous survey results, current literature and discussion amongst the investigators.

RESULTS
23/26 (88%) of invited programs completed the survey. Scope of service: All programs provided neurodevelopmental screening and referral for intervention. Data collection, training and education were provided by most programs (>80%). Therapeutic interventions were offered by a smaller number of programs (>50%). Type of Assessments: The use of Bayley Scales of Infant and Toddler Development increased significantly since 2006. For speech and language, adaptive behavior, and psychological standardized assessments tools a large variation remains. Follow-Up Schedule: Most programs offer between 5 to 7 follow-up visits. There remains a great variability in the timing of visits. Eligibility Criteria: The use of gestational age eligibility criteria, the inclusion of up to 29 weeks, and the expansion to include additional neurologic, cardio-respiratory, and fetal diagnosis has increased since 2006.

CONCLUSION
CNFUN was associated with a clinically important, statistically non-significant standardization. Non-preterm eligibility criteria have increased. Marked variability in Neonatal follow-up practices persist. Standardized follow-up has potential benefits of including facilitating multi-centered research, site benchmarking, and continuity of care for families who move.
HIGH SYSTEMIC BLOOD PRESSURE IN PRETERM INFANTS WITH BRONCHOPULMONARY DYSPLASIA AND LONG-TERM OUTCOMES
Authors: Cayouette Florence , Spénard Sarah , Lapointe Anie , Dorval Véronique , Sommer Julie , Nuyt Anne-Monique 
Published: May 2018

Abstract

BACKGROUND
Bronchopulmonary dysplasia (BPD) is a known risk factor for neurodevelopmental impairment in preterm infants. BPD is also associated with an increased incidence of high systemic blood pressure (HBP). However, it is not known if a diagnosis of HBP in BPD patients relates to later neurodevelopmental outcomes.

OBJECTIVES
We aimed to determine the incidence of neonatal HBP diagnosis in a cohort of preterm infants born <29 weeks of gestational age (GA) with BPD. The secondary objective was to assess if a concomitant diagnosis of BPD and HBP influences neurodevelopmental outcomes at 18 months.

DESIGN/METHODS
We performed a single center retrospective study using data from medical charts. All infants born <29 weeks GA admitted to our level-IV neonatal intensive care unit between January 2010 and December 2012 diagnosed with BPD at 36 weeks of corrected GA were included. Patients transferred before 36 weeks of corrected GA, that died before 18 months or had congenital anomalies were excluded. Patients were classified in the HBP group if HBP was a documented diagnosis in the chart. The control group was the remaining patients with BPD at 36 weeks corrected GA but without HBP. Severe neurodevelopmental impairment at 18 months was defined as either any Bailey-III score <70, cerebral palsy or severe hearing or visual impairment. Descriptive statistics for prenatal and postnatal patients’ characteristics were analyzed. Logistic regression was performed for factors associated with long-term disability. Level of significance was determined as a p value <0.05.

RESULTS
During the study period, 337 preterm infants <29 weeks of GA were identified and after exclusions, 98 newborns met the criteria of BPD at 36 weeks corrected GA. Mean GA and mean birth weight were 26.7 ± 1.7 weeks and 882 ± 199 g respectively. The majority were males (57%) and received antenatal steroids (87.8%). We identified twenty-five newborns (25.5%) with a diagnosis of HBP. Demographic data was similar between the 2 groups. 56% of the HBP group received a post-natal course of steroids, compared to 36% for the control group (p 0.07). The neurodevelopmental outcome at 18 months was similar between the two groups (p 0.54) and was not influenced by the presence of a HBP diagnosis after regression analysis (p 0.8).

CONCLUSION
The diagnosis of HBP was frequent in our cohort of preterm infants born <29 weeks GA with BPD but did not seem to be related to long-term neurodevelopmental outcomes.
GLUTATHIONE ADDITION TO PARENTERAL NUTRITION PREVENTS PULMONARY OXIDATIVE STRESS AND HYPO-ALVEOLARIZATION IN NEWBORN GUINEA PIG
Authors: Lavoie Jean-Claude , Mohamed Ibrahim 
Published: May 2018

Abstract

BACKGROUND
Parenteral nutrition (PN) is contaminated by peroxides, which induce oxidative stress (oxidized redox potential) and hypoalveolarization in lungs of newborn animals. In human premature newborns, PN is associated to an oxidized redox potential and to a greater prevalence of bronchopulmonary dysplasia (BPD). Peroxides are detoxified by glutathione that is deficient in preterm infants. Hypothesis: Improving glutathione level in premature infants prevents BPD development caused by oxidative stress.

OBJECTIVES
Assess dose-response effect of glutathione added in PN on alveolarization index and pulmonary redox potential of glutathione (specific oxidative stress marker for peroxides) in newborn guinea pigs.

DESIGN/METHODS
At day 3 of life, through a jugular catheter, guinea pigs (N=55) received PN (dextrose, amino acids, lipids, vitamins, electrolytes) enriched in glutathione (0, 50, 120, 165, 270, 370, 650 μg GSSG/kg/d). GSSG was used rather than GSH because it has a better stability in PN and similar efficiency in vivo. A control group (no manipulation, fed by mouth) served as reference. After 4 days, lungs were taken for determination of GSH, GSSG, redox potential (capillary electrophoresis) and alveolarization index (AI) (number of intercepts between a 1 mm line and histological structures); higher is AI, higher is the number of alveoli. Data (mean±sem) from animals on PN were compared by ANOVA, p<0.05.

RESULTS
There was no difference in the alveolarization index between groups receiving doses ranging from 0 to 120 μg/kg/d (25.9 ± 0.6 intercepts/mm) and between those with doses ranging between 165 and 650 μg/kg/d (30.5 ± 0.6 intercepts/mm). However, the difference between the lowest (0–120 μg/kg/d) and the highest doses (165–650 μg/kg/d) was highly significant (p<0.001). The control AI value was 29.4 ± 1.2 intercepts/mm. Increasing GSSG in PN has allowed a significant (r2=0.47; p<0.001) reduction of redox potential, from oxidized status of -205 ± 2 in PN without GSSG to -215 ± 2 mV with the highest dose (650 μg/kg/d); control = -222 ± 3 mV. GSSG in PN was also associated with a decreasing GSSG values (r2=0.49; p<0.001), from 0.84 ± 0.10 in PN without GSSG to 0.38 ± 0.06 nmol/mg prot with the highest dose (650 μg/kg/d); control = 0.35 ± 0.07 nmol/mg prot. There was no effect on GSH (mean value of 29 ± 1 nmol/mg prot).

CONCLUSION
Addition of glutathione into PN prevents pulmonary oxidative stress. The dose-response curve suggests a specific minimal dose of GSSG to maintain the alveolar integrity. Lower doses were inefficient whereas higher doses are unnecessary, as the index of alveolarization reached a plateau with a mean value similar to that one observed in the control group. This pre-clinical study brings basic data that will serve for the clinical phase I-II study that we are starting soon.