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Schuh S, Coates AL, Sweeney J, Rumantir M, Eltorki M, Alqurashi W, Plint AC, Zemek R, Poonai N, Parkin PC, Soares D, Moineddin R, Finkelstein Y. Nasal Suctioning Therapy Among Infants With Bronchiolitis Discharged Home From the Emergency Department: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2337810. [PMID: 37856126 PMCID: PMC10587796 DOI: 10.1001/jamanetworkopen.2023.37810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/18/2023] [Indexed: 10/20/2023] Open
Abstract
Importance Although nasal suctioning is the most frequently used supportive management for bronchiolitis, its benefit remains unknown. Objective To evaluate the effectiveness of enhanced vs minimal nasal suctioning in treating infants with bronchiolitis after discharge from the emergency department (ED). Design, Setting, and Participants This single-blind, parallel-group, randomized clinical trial was conducted from March 6, 2020, to December 15, 2022, at 4 tertiary-care Canadian pediatric EDs. Participants included otherwise healthy infants aged 1 to 11 months with a diagnosis of bronchiolitis who were discharged home from the ED. Interventions Participants were randomized to minimal suctioning via bulb or enhanced suctioning via a battery-operated device before feeding for 72 hours. Main Outcomes and Measures The primary outcome was additional resource use, a composite of unscheduled revisits for bronchiolitis or use of additional suctioning devices for feeding and/or breathing concerns. Secondary outcomes included health care utilization, feeding and sleeping adequacy, and satisfaction. Results Of 884 screened patients, 352 were excluded for criteria, 79 declined participation, 81 were otherwise excluded, 372 were randomized (185 to the minimal suction group and 187 to the enhanced suction group), and 367 (median [IQR] age, 4 [2-6] months; 221 boys [60.2%]) completed the trial (184 in the minimal suction and 183 in the enhanced suction group). Additional resource use occurred for 68 of 184 minimal suction participants (37.0%) vs 48 of 183 enhanced suction participants (26.2%) (absolute risk difference, 0.11; 95% CI, 0.01 to 0.20; P = .03). Unscheduled revisits occurred for 47 of 184 minimal suction participants (25.5%) vs 40 of 183 enhanced suction participants (21.9%) (absolute risk difference, 0.04; 95% CI, -0.05 to 0.12; P = .46). A total of 33 of 184 parents in the minimal suction group (17.9%) used additional suctioning devices vs 11 of 183 parents in the enhanced suction group (6.0%) (absolute risk difference, 0.12; 95% CI, 0.05 to 0.19; P < .001). No significant between-group differences were observed for all bronchiolitis revisits (absolute risk difference, 0.07; 95% CI, -0.02 to 0.16; P = .15), ED revisits (absolute risk difference, 0.04; 95% CI, -0.03 to 0.12; P = .30), parental care satisfaction (absolute risk difference, -0.02; 95% CI, -0.10 to 0.06; P = .70), and changes from baseline to 72 hours in normal feeding (difference in differences, 0.03; 95% CI, -0.10 to 0.17; P = .62), normal sleeping (difference in differences, 0.05; 95% CI, -0.08 to 0.18; P = .47), or normal parental sleeping (difference in differences, 0.10; 95% CI, -0.02 to 0.23; P = .09). Parents in the minimal suction group were less satisfied with the assigned device (62 of 184 [33.7%]) than parents in the enhanced suction group (145 of 183 [79.2%]) (risk difference, 0.45; 95% CI, 0.36 to 0.54; P < .001). Conclusions and Relevance Compared with minimal suctioning, enhanced suctioning after ED discharge with bronchiolitis did not alter the disease course because there were no group differences in revisits or feeding and sleeping adequacy. Minimal suctioning resulted in higher use of nonassigned suctioning devices and lower parental satisfaction with the assigned device. Trial Registration ClinicalTrials.gov Identifier: NCT03361371.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Allan L. Coates
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Judy Sweeney
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maggie Rumantir
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, McMaster Children’s Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Amy C. Plint
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Roger Zemek
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Naveen Poonai
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Children’s Health Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Patricia C. Parkin
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Diane Soares
- Department of Respiratory Therapy, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Aronson PL, Schaeffer P, A Ponce K, K Gainey T, Politi MC, Fraenkel L, Florin TA. Stakeholder Perspectives on Hospitalization Decisions and Shared Decision-Making in Bronchiolitis. Hosp Pediatr 2022; 12:473-482. [PMID: 35441213 PMCID: PMC9647631 DOI: 10.1542/hpeds.2021-006475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Our objective was to elicit clinicians' and parents' perspectives about decision-making related to hospitalization for children with bronchiolitis and the use of shared decision-making (SDM) to guide these decisions. METHODS We conducted individual, semistructured interviews with purposively sampled clinicians (pediatric emergency medicine physicians and nurses) at 2 children's hospitals and parents of children age <2 years with bronchiolitis evaluated in the emergency department at 1 hospital. Interviews elicited clinicians' and parents' perspectives on decision-making and SDM for bronchiolitis. We conducted an inductive analysis following the principles of grounded theory until data saturation was reached for both groups. RESULTS We interviewed 24 clinicians (17 physicians, 7 nurses) and 20 parents. Clinicians identified factors in 3 domains that contribute to hospitalization decision-making for children with bronchiolitis: demographics, clinical factors, and social-emotional factors. Although many clinicians supported using SDM for hospitalization decisions, most reported using a clinician-guided decision-making process in practice. Clinicians also identified several barriers to SDM, including the unpredictable course of bronchiolitis, perceptions of parents' preferences for engaging in SDM, and parents' emotions, health literacy, preferred language, and comfort with discharge. Parents wanted the opportunity to express their opinions during decision-making about hospitalization, although they often felt comfortable with the clinician's decision when adequately informed. CONCLUSIONS Although clinicians and parents of children with bronchiolitis are supportive of SDM, most hospitalization decision-making is clinician guided. Future investigation should evaluate how to address barriers and implement SDM in practice, including training clinicians in this SDM approach.
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Affiliation(s)
| | | | | | | | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University, St Louis, Missouri
| | - Liana Fraenkel
- Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Todd A Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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3
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Hartmann K, Liese JG, Kemmling D, Prifert C, Weißbrich B, Thilakarathne P, Diels J, Weber K, Streng A. Clinical Burden of Respiratory Syncytial Virus in Hospitalized Children Aged ≤5 years (INSPIRE Study). J Infect Dis 2022; 226:386-395. [PMID: 35417015 PMCID: PMC9417125 DOI: 10.1093/infdis/jiac137] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Respiratory syncytial virus (RSV) is a leading cause of hospitalizations in children (≤5 years of age); limited data compare burden by age. Methods This single-center retrospective study included children (≤5 years of age) hospitalized for >24 hours with reverse-transcription polymerase chain reaction (RT-PCR)–confirmed RSV infection (2015–2018). Hospital length of stay (LOS), intensive care unit (ICU) admissions, ICU LOS, supplemental oxygen, and medication use were assessed. Multivariate logistic regression analyses identified predictors of hospital LOS >5 days. Results Three hundred twelve patients had RSV infection (ages 0 to <6 months [35%], 6 to <12 months [15%], 1 to <2 years [25%], and 2–5 years [25%]); 16.3% had predefined comorbidities (excludes preterm infants). Median hospital LOS was 5.0 days and similar across age; 5.1% (16/312) were admitted to ICU (ICU LOS, 5.0 days), with those aged 0 to <6 months admitted most frequently (10/108 [9.3%]). Supplemental oxygen was administered in 57.7% of patients, with similar need across ages. Antibiotics were administered frequently during hospitalization (43.6%). Predictors of prolonged LOS included pneumonia (odds ratio [OR], 2.33), supplemental oxygen need (OR, 5.09), and preterm births (OR, 3.37). High viral load (RT-PCR RSV cycle threshold value <25) was associated with greater need for supplemental oxygen. Conclusions RSV causes substantial burden in hospitalized children (≤5 years), particularly preterm infants and those aged <6 months.
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Affiliation(s)
- Katrin Hartmann
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Johannes G Liese
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Daniel Kemmling
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
| | - Christiane Prifert
- Institute of Virology and Immunobiology, University of Würzburg, Würzburg, Germany
| | - Benedikt Weißbrich
- Institute of Virology and Immunobiology, University of Würzburg, Würzburg, Germany
| | | | | | - Karin Weber
- Global Medical Affairs, IDV, Janssen-Cilag, Vienna, Austria
| | - Andrea Streng
- Department of Pediatrics, University Hospital Würzburg, Würzburg, Germany
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Natarajan E, Florin TA, Constantinou C, Aronson PL. What Is the Role of Shared Decision-Making With Parents of Children With Bronchiolitis? Hosp Pediatr 2022; 12:e50-e53. [PMID: 34972216 PMCID: PMC9667985 DOI: 10.1542/hpeds.2021-006245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Eesha Natarajan
- Pediatric Residency Program, Department of Pediatrics,Address correspondence to Eesha Natarajan, MBBS, Department of Pediatrics, Yale New Haven Hospital, 1 Park St, West Pavilion, 7th floor, New Haven, CT 06504. E-mail:
| | - Todd A. Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christina Constantinou
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, School of Medicine, Yale University, New Haven, Connecticut
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Sander B, Finkelstein Y, Lu H, Nagamuthu C, Graves E, Ramsay LC, Kwong JC, Schuh S. Healthcare cost attributable to bronchiolitis: A population-based cohort study. PLoS One 2021; 16:e0260809. [PMID: 34855892 PMCID: PMC8639079 DOI: 10.1371/journal.pone.0260809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/17/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine 1-year attributable healthcare costs of bronchiolitis. METHODS Using a population-based matched cohort and incidence-based cost analysis approach, we identified infants <12 months old diagnosed in an emergency department (ED) or hospitalized with bronchiolitis between April 1, 2003 and March 31, 2014. We propensity-score matched infants with and without bronchiolitis on sex, age, income quintile, rurality, co-morbidities, gestational weeks, small-for-gestational-age status and pre-index healthcare cost deciles. We calculated mean attributable 1-year costs using a generalized estimating equation model and stratified costs by age, sex, income quintile, rurality, co-morbidities and prematurity. RESULTS We identified 58,375 infants with bronchiolitis (mean age 154±95 days, 61.3% males, 4.2% with comorbidities). Total 1-year mean bronchiolitis-attributable costs were $4,313 per patient (95%CI: $4,148-4,477), with $2,847 (95%CI: $2,712-2,982) spent on hospitalizations, $610 (95%CI: $594-627) on physician services, $562 (95%CI: $556-567)] on ED visits, $259 (95%CI: $222-297) on other healthcare costs and $35 ($27-42) on drugs. Attributable bronchiolitis costs were $2,765 (95%CI: $2735-2,794) vs $111 (95%CI: $102-121) in the initial 10 days post index date, $4,695 (95%CI: $4,589-4,800) vs $910 (95%CI: $847-973) in the initial 180 days and $1,158 (95%CI: $1,104-1213) vs $639 (95%CI: $599-679) during days 181-360. Mean 1-year bronchiolitis costs were higher in infants <3 months old [$5,536 (95%CI: $5,216-5,856)], those with co-morbidities [$17,530 (95%CI: $14,683-20,377)] and with low birthweight [$5,509 (95%CI: $4,927-6,091)]. CONCLUSIONS Compared to no bronchiolitis, bronchiolitis incurs five-time and two-time higher healthcare costs within the initial and subsequent six-months, respectively. Most expenses occur in the initial 10 days and relate to hospitalization.
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Affiliation(s)
- Beate Sander
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
- * E-mail:
| | - Yaron Finkelstein
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Research Institute, Division of Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hong Lu
- ICES, Toronto, Ontario, Canada
| | | | | | - Lauren C. Ramsay
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey C. Kwong
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
| | - Suzanne Schuh
- University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Research Institute, Division of Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
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Gill PJ, Anwar MR, Kornelsen E, Parkin P, Mahood Q, Mahant S. Parenteral versus enteral fluid therapy for children hospitalised with bronchiolitis. Cochrane Database Syst Rev 2021; 12:CD013552. [PMID: 34852398 PMCID: PMC8635777 DOI: 10.1002/14651858.cd013552.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The main focus of treatment for children hospitalised with bronchiolitis is supportive, including oxygen supplementation, respiratory support, and fluid therapy. Up to half of infants hospitalised with bronchiolitis require non-oral fluid therapy due to dehydration or concerns related to the safety of oral feeding. The two main modalities used for non-oral fluid therapy are parenteral (intravenous (IV)) and enteral tube (nasogastric (NG) or orogastric (OG)). However, it is not known which mode is optimal in young children. OBJECTIVES To systematically review randomised clinical trials (RCTs) of the effectiveness and safety of parenteral and enteral tube fluid therapy for children under two years of age hospitalised with bronchiolitis. SEARCH METHODS We conducted a search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 March 2021. We handsearched conference proceedings, conducted forward and backward searching of citation lists of relevant articles, and contacted experts. SELECTION CRITERIA We included RCTs and quasi-RCTs of children aged up to two years admitted to hospital with a clinical diagnosis of bronchiolitis who required fluid therapy. The trials compared enteral tube fluid therapy with parenteral fluid therapy. The primary outcome was difference in length of hospital stay in hours after each non-oral fluid therapy modality. As actual time of discharge can be impacted by various factors, we also assessed theoretical length of stay (i.e. time when a patient is safe for discharge). We assessed several secondary outcomes. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS: The searches yielded 615 unique records, of which four articles underwent full-text screening. We included two trials (810 children). Oakley 2013 was an open, non-blinded RCT of infants aged two to 12 months admitted to hospitals in Australia and New Zealand with a clinical diagnosis of bronchiolitis during three bronchiolitis seasons. The trial enrolled 759 children, of which 381 were randomised to NG tube therapy and 378 to IV therapy. Risk of bias was low in most domains. Kugelman 2013 was an open, non-blinded RCT that enrolled infants aged less than six months with a clinical diagnosis of "moderate bronchiolitis" at a single hospital in Israel. The study enrolled 51 infants, of which 31 were assigned to NG or OG tube therapy and 20 to IV therapy. Risk of bias was unclear in most domains. The application of enteral tube fluid therapy compared to IV fluid therapy probably makes little to no difference for actual length of hospital stay (mean difference (MD) 6.8 hours, 95% confidence interval (CI) -4.7 to 18.4 hours; 2 studies, 810 children, moderate certainty evidence). There was also little to no difference for theoretical length of stay (MD 4.4 hours, 95% CI -3.6 to 12.4 hours; 2 studies, 810 children, moderate certainty evidence). For the secondary outcomes, enteral tube fluid therapy probably makes little to no difference for time to resume full oral feeding compared to IV fluid therapy (MD 2.8 hours, 95% CI -3.6 to 9.2 hours; 2 studies, 810 children, moderate certainty evidence). The use of enteral tube for fluid therapy probably results in a large increase in the success of insertion of fluid modality at first attempt (risk ratio (RR) 1.52, 95% CI 1.36 to 1.69; 1 study, 617 children, moderate certainty evidence), and probably largely reduces the chances of change in fluid therapy modality (RR 0.52, 95% CI 0.38 to 0.71; 1 study, 759 children, moderate certainty evidence) compared to IV fluid. Oakley 2013 reported 47 local complication events after discharge in the IV fluid group compared to 30 events in the NG tube group. They also evaluated parental satisfaction, which was high with both modalities. Enteral tube fluid therapy makes little to no difference to the duration of oxygen supplementation (MD 2.2 hours, 95% CI -5.0 to 9.5 hours; 2 studies, 810 children, moderate certainty evidence). Compared with the IV fluid therapy group, there was a 17% relative reduction in the number of intensive care unit admissions (RR 0.83, 95% CI 0.47 to 1.46; 1 study, 759 children, moderate certainty evidence) and a 19% relative reduction in number of readmissions to hospital (RR 0.81, 95% CI 0.33 to 2.04; 1 study, 678 children, moderate certainty evidence) in the enteral tube fluid therapy group. Adverse events were uncommon in both trials, with likely little to no differences between groups. AUTHORS' CONCLUSIONS Based on two RCTs, enteral tube feeding likely results in little to no difference in length of hospital stay compared with the IV fluid group. However, enteral tube fluid therapy likely results in a large increase in the success of insertion of fluid modality at first attempt, and a large reduction in change in modality of fluid therapy. It also probably reduces local complications compared to the IV fluid group. Despite bronchiolitis being one of the most prevalent childhood conditions, we identified only two studies with under 1000 participants in total, which highlights the need for multicentre trials. Future studies should explore type of fluid administered, parent-reported outcomes and preferences, and the role of shared decision-making.
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Affiliation(s)
- Peter J Gill
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Mohammed Rashidul Anwar
- Child Health Evaluation Sciences, The Hospital for Sick Children (SickKids), Toronto, Canada
| | | | - Patricia Parkin
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Quenby Mahood
- The Hospital for Sick Children (SickKids), Toronto, Canada
| | - Sanjay Mahant
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Schondelmeyer AC, Bettencourt AP, Xiao R, Beidas RS, Wolk CB, Landrigan CP, Brady PW, Brent CR, Parthasarathy P, Kern-Goldberger AS, Sergay N, Lee V, Russell CJ, Prasto J, Zaman S, McQuistion K, Lucey K, Solomon C, Garcia M, Bonafide CP. Evaluation of an Educational Outreach and Audit and Feedback Program to Reduce Continuous Pulse Oximetry Use in Hospitalized Infants With Stable Bronchiolitis: A Nonrandomized Clinical Trial. JAMA Netw Open 2021; 4:e2122826. [PMID: 34473258 PMCID: PMC8414187 DOI: 10.1001/jamanetworkopen.2021.22826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE National guidelines recommend against continuous pulse oximetry use for hospitalized children with bronchiolitis who are not receiving supplemental oxygen, yet guideline-discordant use remains high. OBJECTIVES To evaluate deimplementation outcomes of educational outreach and audit and feedback strategies aiming to reduce guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen. DESIGN, SETTING, AND PARTICIPANTS A nonrandomized clinical single-group deimplementation trial was conducted in 14 non-intensive care units in 5 freestanding children's hospitals and 1 community hospital from December 1, 2019, through March 14, 2020, among 847 nurses and physicians caring for hospitalized children with bronchiolitis who were not receiving supplemental oxygen. INTERVENTIONS Educational outreach focused on communicating details of the existing guidelines and evidence. Audit and feedback strategies included 2 formats: (1) weekly aggregate data feedback to multidisciplinary teams with review of unit-level and hospital-level use of continuous pulse oximetry, and (2) real-time 1:1 feedback to clinicians when guideline-discordant continuous pulse oximetry use was discovered during in-person data audits. MAIN OUTCOMES AND MEASURES Clinician ratings of acceptability, appropriateness, feasibility, and perceived safety were assessed using a questionnaire. Guideline-discordant continuous pulse oximetry use in hospitalized children was measured using direct observation of a convenience sample of patients with bronchiolitis who were not receiving supplemental oxygen. RESULTS A total of 847 of 1193 eligible clinicians (695 women [82.1%]) responded to a Likert scale-based questionnaire (71% response rate). Most respondents rated the deimplementation strategies of education and audit and feedback as acceptable (education, 435 of 474 [92%]; audit and feedback, 615 of 664 [93%]), appropriate (education, 457 of 474 [96%]; audit and feedback, 622 of 664 [94%]), feasible (education, 424 of 474 [89%]; audit and feedback, 557 of 664 [84%]), and safe (803 of 847 [95%]). Sites collected 1051 audit observations (range, 47-403 per site) on 709 unique patient admissions (range, 31-251 per site) during a 3.5-month period of continuous pulse oximetry use in children with bronchiolitis not receiving supplemental oxygen, which were compared with 579 observations (range, 57-154 per site) from the same hospitals during the baseline 4-month period (prior season) to determine whether the strategies were associated with a reduction in use. Sites conducted 148 in-person educational outreach and aggregate data feedback sessions and provided real-time 1:1 feedback 171 of 236 times (72% of the time when guideline-discordant monitoring was identified). Adjusted for age, gestational age, time since weaning from supplemental oxygen, and other characteristics, guideline-discordant continuous pulse oximetry use decreased from 53% (95% CI, 49%-57%) to 23% (95% CI, 20%-25%) (P < .001) during the intervention period. There were no adverse events attributable to reduced monitoring. CONCLUSIONS AND RELEVANCE In this nonrandomized clinical trial, educational outreach and audit and feedback deimplementation strategies for guideline-discordant continuous pulse oximetry use among hospitalized children with bronchiolitis who were not receiving supplemental oxygen were positively associated with clinician perceptions of feasibility, acceptability, appropriateness, and safety. Evaluating the sustainability of deimplementation beyond the intervention period is an essential next step. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04178941.
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Affiliation(s)
- Amanda C. Schondelmeyer
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Amanda P. Bettencourt
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Rinad S. Beidas
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
| | - Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Patrick W. Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Canita R. Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Padmavathy Parthasarathy
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Andrew S. Kern-Goldberger
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nathaniel Sergay
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Pediatric Residency Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vivian Lee
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Christopher J. Russell
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Julianne Prasto
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of Pediatrics, Children’s Hospital of Philadelphia Pediatric Care and Penn Medicine Princeton Medical Center, Philadelphia, Pennsylvania
| | - Sarah Zaman
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
| | - Kaitlyn McQuistion
- University of Washington Pediatric Residency Program, Department of Pediatrics, University of Washington, Seattle
| | - Kate Lucey
- Division of Hospital Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Courtney Solomon
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas
- Division of Pediatric Hospital Medicine, Children’s Health Dallas, Texas
| | - Mayra Garcia
- Division of General and Thoracic Surgery, Children’s Health Dallas, Dallas, Texas
| | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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8
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Buendía JA, Acuña-Cordero R, Rodriguez-Martinez CE. [Predictors of hospitalization plus airway support among infants with recurrent wheezing in the emergency department]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:438-444. [PMID: 34020730 PMCID: PMC8140345 DOI: 10.7499/j.issn.1008-8830.2011106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/09/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Most patients with recurrent wheezing are infants under 2 years of age. Clinical prediction models of the risk of receiving airway support during the hospital stay in this population have been poorly studied in tropical countries. This study aimed to evaluate the clinical predictors of hospitalization plus airway support among infants with recurrent wheezing evaluated in the emergency department in Colombia. METHODS A retrospective cohort study was performed. This study included all infants with two or more wheezing episodes who were younger than two years old in two tertiary centers in Rionegro, Colombia, between January 2019 and December 2019. The primary outcome measure was hospitalization plus any airway support. A multivariable logistic regression model was used to identify factors independently associated with hospitalization plus any airway support. RESULTS A total of 85 infants were hospitalized plus any airway support, of whom 34(40%) were treated with high flow nasal canula, 2(2%) received non-invasive ventilation, 6(7%) were mechanically ventilated, and 43 (51%) received conventional oxygen therapy. The multivariable logistic regression model showed that predictors of hospitalization plus airway support included prematurity (OR=1.79, 95%CI: 1.04-3.10), poor feeding (OR=2.22, 95%CI: 1.25-3.94), nasal flaring and/or grunting (OR=4.27, 95%CI: 2.41-7.56), and previous wheezing episodes requiring hospitalization (OR=3.36, 95%CI: 1.86-7.08). The model has a high specificity (99.6%) with acceptable discrimination and an area under the curve of 0.70(95%CI: 0.60-0.74). CONCLUSIONS The present study shows that prematurity, poor feeding, nasal flaring and/or grunting, and more than one previous episode of wheezing requiring hospitalization are independent predictors of hospitalization plus airway support in a population of infants with recurrent wheezing in the emergency department. More evidence must be collected to examine the results in other tropical countries.
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Affiliation(s)
- Jefferson Antonio Buendía
- Department of Pharmacology and Toxicology, School of Medicine, Research Group in Pharmacology and Toxicology (INFARTO), Universidad de Antioquia, Medellín, ColombiaDepartment of Pharmacology and Toxicology, School of Medicine, Research Group in Pharmacology and Toxicology (INFARTO), Universidad de Antioquia, Medellín, Colombia
| | - Ranniery Acuña-Cordero
- Departamento de Neumología Pediátrica, Hospital Militar Central, Departamento de Pediatría, Facultad de Medicina, Universidad Militar Nueva Granada, Bogotá, Colombia
| | - Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
- Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
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Milési C, Requirand A, Douillard A, Baleine J, Nogué E, Matecki S, Amedro P, Pons-Odena M, Cambonie G. Assessment of Peak Inspiratory Flow in Young Infants with Acute Viral Bronchiolitis: Physiological Basis for Initial Flow Setting in Patients Supported with High-Flow Nasal Cannula. J Pediatr 2021; 231:239-245.e1. [PMID: 33333115 DOI: 10.1016/j.jpeds.2020.12.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/20/2020] [Accepted: 12/10/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To assess the inspiratory demand in young infants with acute viral bronchiolitis to provide a physiological basis for initial flow setting for patients supported with high flow nasal cannula. STUDY DESIGN Prospective study in 44 infants up to 6 months old with acute viral bronchiolitis, admitted to a pediatric intensive care unit from November 2017 to March 2019. Airflow measurements were performed using spirometry. The primary endpoint was the inspiratory demand as measured by peak tidal inspiratory flow (PTIF). The secondary endpoints were the relationships determined between PTIF, patient weight, and disease severity. RESULTS Median (Q25-Q75) age and weight of the patients were 37 (20-67) days and 4.3 (3.5-5.0) kg, respectively. Mean PTIF was 7.45 (95% CI 6.51-8.39, min-max: 2.40-16.00) L/minute. PTIF indexed to weight was 1.68 (95% CI 1.51-1.85, min-max: 0.67-3.00) L/kg/minute. PTIF was <2.5 L/kg/minute in 89% (95% CI 75-96) of infants. PTIF was correlated with weight (ρ= 0 .55, P < .001) but not with markers of disease severity, including modified Woods clinical asthma score, Silverman-Andersen score, respiratory rate, fraction of inspired oxygen, and PCO2. CONCLUSIONS High flow nasal cannula therapy is used commonly to support infants with acute viral bronchiolitis. The efficiency of the device is optimal if the flow setting matches the patient's inspiratory demand. According to our results, a flow rate of <2.5 L/kg/minute would be appropriate in most situations.
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Affiliation(s)
- Christophe Milési
- Pediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
| | - Anne Requirand
- Pediatric Functional Exploration Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Aymeric Douillard
- Department of Medical Information, Montpellier University Hospital Center, Montpellier, France
| | - Julien Baleine
- Pediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
| | - Erika Nogué
- Department of Medical Information, Montpellier University Hospital Center, Montpellier, France
| | - Stephan Matecki
- Pediatric Functional Exploration Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France; PHYMEDEXP, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France
| | - Pascal Amedro
- PHYMEDEXP, CNRS UMR 9214, INSERM U1046, University of Montpellier, Montpellier, France; Pediatric Cardiology and Pulmonology Department, M3C Regional Reference Center, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Marti Pons-Odena
- Pediatric Intensive Care Unit, Sant Joan de Deu University Hospital Center, University of Barcelona, Esplugues de Llobregat, Barcelona, Spain
| | - Gilles Cambonie
- Pediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France; Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France.
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10
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Maki K, Azizi H, Hans P, Doan Q. Adherence to national paediatric bronchiolitis management guidelines and impact on emergency department resource utilization. Paediatr Child Health 2021; 26:108-113. [DOI: 10.1093/pch/pxaa013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/13/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
To evaluate the association between the use of nonrecommended pharmacology (salbutamol and corticosteroids) per national bronchiolitis guidelines, either during the index visit or at discharge, and system utilization measures (frequency of return visits [RTED] and on paediatric emergency department [PED] length of stay [LOS]).
Study Design
We conducted a retrospective case control study of 185 infants (≤12 months old) who presented to the PED between December 2014 and April 2017 and discharged home with a clinical diagnosis of bronchiolitis. Inclusion criteria included ≥ 1 viral prodromal symptom and ≥ 1 physical exam finding of respiratory distress. Cases were defined as infants who had ≥ 1 RTED within 7 days of their index visit and controls were matched for age and acuity but without RTED. Logistic regression analysis and multivariable linear regression were used to assess the odds of RTED and PED LOS associated with nonadherence to pharmaceutical recommendations per AAP and CPS bronchiolitis guidelines.
Results
Use of nonrecommended pharmacology per national bronchiolitis guidelines was documented among 39% of the 185 study participants. Adjusting for acuity of index visit, age, severe tachypnea, oxygen desaturation, and dehydration, use of nonrecommended pharmacology was not associated with RTED (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.47 to 2.03). Use of salbutamol and corticosteroids, however, were each independently associated with increased PED LOS (58.3 minutes [P=0.01] and 116.7 minutes [P<0.001], respectively).
Conclusion
Nonadherence to the pharmaceutical recommendations of national bronchiolitis guidelines was not associated with RTED but salbutamol and corticosteroid use increased PED LOS.
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Affiliation(s)
- Kate Maki
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
- BC Children’s Hospital Research Institute, Vancouver, British Columbia
| | - Hawmid Azizi
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Prabhjas Hans
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Quynh Doan
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
- BC Children’s Hospital Research Institute, Vancouver, British Columbia
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11
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Havdal LB, Nakstad B, Fjærli HO, Ness C, Inchley C. Viral lower respiratory tract infections-strict admission guidelines for young children can safely reduce admissions. Eur J Pediatr 2021; 180:2473-2483. [PMID: 33834273 PMCID: PMC8285352 DOI: 10.1007/s00431-021-04057-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/13/2021] [Accepted: 03/29/2021] [Indexed: 01/11/2023]
Abstract
Viral lower respiratory tract infection (VLRTI) is the most common cause of hospital admission among small children in high-income countries. Guidelines to identify children in need of admission are lacking in the literature. In December 2012, our hospital introduced strict guidelines for admission. This study aims to retrospectively evaluate the safety and efficacy of the guidelines. We performed a single-center retrospective administrative database search and medical record review. ICD-10 codes identified children < 24 months assessed at the emergency department for VLRTI for a 10-year period. To identify adverse events related to admission guidelines implementation, we reviewed patient records for all those discharged on primary contact followed by readmission within 14 days. During the study period, 3227 children younger than 24 months old were assessed in the ED for VLRTI. The proportion of severe adverse events among children who were discharged on their initial emergency department contact was low both before (0.3%) and after the intervention (0.5%) (p=1.0). Admission rates before vs. after the intervention were for previously healthy children > 90 days 65.3% vs. 53.3% (p<0.001); for healthy children ≤ 90 days 85% vs. 68% (p<0.001); and for high-risk comorbidities 74% vs. 71% (p=0.5).Conclusion: After implementation of admission guidelines for VLRTI, there were few adverse events and a significant reduction in admissions to the hospital from the emergency department. Our admission guidelines may be a safe and helpful tool in the assessment of children with VLRTI. What is Known: • Viral lower respiratory tract infection, including bronchiolitis, is the most common cause of hospitalization for young children in the developed world. Treatment is mainly supportive, and hospitalization should be limited to the cases in need of therapeutic intervention. • Many countries have guidelines for the management of the disease, but the decision on whom to admit for inpatient treatment is often subjective and may vary even between physicians in the same hospital. What is New: • Implementation of admission criteria for viral lower respiratory tract infection may reduce the rate of hospital admissions without increasing adverse events.
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Affiliation(s)
- Lise Beier Havdal
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway. .,Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Britt Nakstad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hans Olav Fjærli
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
| | - Christian Ness
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
| | - Christopher Inchley
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
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12
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Wolk CB, Schondelmeyer AC, Barg FK, Beidas R, Bettencourt A, Brady PW, Brent C, Eriksen W, Kinkler G, Landrigan CP, Neergaard R, Bonafide CP. Barriers and Facilitators to Guideline-Adherent Pulse Oximetry Use in Bronchiolitis. J Hosp Med 2021; 16:23-30. [PMID: 33357326 PMCID: PMC7768921 DOI: 10.12788/jhm.3535] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/09/2020] [Accepted: 09/13/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Continuous pulse oximetry monitoring (cSpO2) in children with bronchiolitis does not improve clinical outcomes and has been associated with increased resource use and alarm fatigue. It is critical to understand the factors that contribute to cSpO2 overuse in order to reduce overuse and its associated harms. METHODS This multicenter qualitative study took place in the context of the Eliminating Monitor Overuse (EMO) SpO2 study, a cross-sectional study to establish rates of cSpO2 in bronchiolitis. We conducted semistructured interviews, informed by the Consolidated Framework for Implementation Research, with a purposive sample of stakeholders at sites with high and low cSpO2 use rates to identify barriers and facilitators to addressing cSpO2 overuse. Interviews were audio recorded and transcribed. Analyses were conducted using an integrated approach. RESULTS Participants (n = 56) included EMO study site principal investigators (n = 12), hospital administrators (n = 8), physicians (n = 15), nurses (n = 12), and respiratory therapists (n = 9) from 12 hospitals. Results suggest that leadership buy-in, clear authoritative guidelines for SpO2 use incorporated into electronic order sets, regular education about cSpO2 in bronchiolitis, and visual reminders may be needed to reduce cSpO2 utilization. Parental perceptions and individual clinician comfort affect cSpO2 practice. CONCLUSION We identified barriers and facilitators to deimplementation of cSpO2 for stable patients with bronchiolitis across children's hospitals with high- and low-cSpO2 use. Based on these data, future deimplementation efforts should focus on clear protocols for cSpO2, EHR changes, and education for hospital staff on bronchiolitis features and rationale for reducing cSpO2.
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Affiliation(s)
- Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda C Schondelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Frances K Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rinad Beidas
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda Bettencourt
- Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan, Ann Arbor, Michigan
| | - Patrick W Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Canita Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Whitney Eriksen
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Grace Kinkler
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rebecca Neergaard
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Kenmoe S, Kengne-Nde C, Ebogo-Belobo JT, Mbaga DS, Fatawou Modiyinji A, Njouom R. Systematic review and meta-analysis of the prevalence of common respiratory viruses in children < 2 years with bronchiolitis in the pre-COVID-19 pandemic era. PLoS One 2020; 15:e0242302. [PMID: 33180855 PMCID: PMC7660462 DOI: 10.1371/journal.pone.0242302] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/01/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction The advent of genome amplification assays has allowed description of new respiratory viruses and to reconsider the role played by certain respiratory viruses in bronchiolitis. This systematic review and meta-analysis was initiated to clarify the prevalence of respiratory viruses in children with bronchiolitis in the pre-COVID-19 pandemic era. Methods We performed an electronic search through Pubmed and Global Index Medicus databases. We included observational studies reporting the detection rate of common respiratory viruses in children with bronchiolitis using molecular assays. Data was extracted and the quality of the included articles was assessed. We conducted sensitivity, subgroups, publication bias, and heterogeneity analyses using a random effect model. Results The final meta-analysis included 51 studies. Human respiratory syncytial virus (HRSV) was largely the most commonly detected virus 59.2%; 95% CI [54.7; 63.6]). The second predominant virus was Rhinovirus (RV) 19.3%; 95% CI [16.7; 22.0]) followed by Human bocavirus (HBoV) 8.2%; 95% CI [5.7; 11.2]). Other reported viruses included Human Adenovirus (HAdV) 6.1%; 95% CI [4.4; 8.0]), Human Metapneumovirus (HMPV) 5.4%; 95% CI [4.4; 6.4]), Human Parainfluenzavirus (HPIV) 5.4%; 95% CI [3.8; 7.3]), Influenza 3.2%; 95% CI [2.2; 4.3], Human Coronavirus (HCoV) 2.9%; 95% CI [2.0; 4.0]), and Enterovirus (EV) 2.9%; 95% CI [1.6; 4.5]). HRSV was the predominant virus involved in multiple detection and most codetections were HRSV + RV 7.1%, 95% CI [4.6; 9.9]) and HRSV + HBoV 4.5%, 95% CI [2.4; 7.3]). Conclusions The present study has shown that HRSV is the main cause of bronchiolitis in children, we also have Rhinovirus, and Bocavirus which also play a significant role. Data on the role played by SARS-CoV-2 in children with acute bronchiolitis is needed. Review registration PROSPERO, CRD42018116067.
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Affiliation(s)
- Sebastien Kenmoe
- Department of Virology, Centre Pasteur of Cameroon, Yaoundé, Cameroon
| | - Cyprien Kengne-Nde
- National AIDS Control Committee, Epidemiological Surveillance, Evaluation and Research Unit, Yaounde, Cameroon
| | - Jean Thierry Ebogo-Belobo
- Medical Research Centre, Institute of Medical Research and Medicinal Plants Studies, Yaoundé, Cameroon
| | - Donatien Serge Mbaga
- Department of Microbiology, Faculty of Science, The University of Yaounde I, Yaoundé, Cameroon
| | - Abdou Fatawou Modiyinji
- Department of Virology, Centre Pasteur of Cameroon, Yaoundé, Cameroon
- Department of Animals Biology and Physiology, Faculty of Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Richard Njouom
- Department of Virology, Centre Pasteur of Cameroon, Yaoundé, Cameroon
- * E-mail: ,
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14
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Roué JM, Delpeut J, d'Hennezel A, Tierrie T, Barzic A, L'Her E, Cros P. Automatic oxygen flow titration in spontaneously breathing children: An open-label randomized controlled pilot study. Pediatr Pulmonol 2020; 55:3180-3188. [PMID: 32827344 DOI: 10.1002/ppul.25035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 08/14/2020] [Indexed: 11/11/2022]
Abstract
INTRODUCTION When children require supplemental oxygen due to acute hypoxemic respiratory distress (AHRD), manual control of the oxygen flow is often difficult and time-consuming, and carries the risk of unrecognized hypoxia and hyperoxia. To date, no automatic oxygen titration system has been developed and evaluated in spontaneously breathing children. METHODS Children between 1 month and 15 years of age receiving supplemental oxygen due to AHRD were recruited within 24 hours following the onset of the O2 administration in a French University Department of Paediatrics. Patients were randomized to receive either automated oxygen administration using the FreeO2 device, or conventional manual oxygen administration over a maximum period of 6 hours. Stratification was performed to classify the patients into two age groups: 1 month to 2 years of age and 2 to 15 years of age. The primary outcome was % time spent within the SpO2 target range (92%-98%). RESULTS 60 patients (30 infants, 30 children) were randomized and 55 could be analyzed for the primary outcome (28 automated, 27 manual). The automated O2 delivery using the FreeO2 device significantly increased the time spent within the predefined SpO2 range (94.6% ± 6% vs 76.3% ± 22%, difference [95% confidence interval {CI}] 18.4 [10.1; 26.7]) with less time spent with hypoxemia (1% ± 1.1% vs 15.1% ± 21.8%, difference [95% CI] -14.4 [-22.2; -6.7]). This difference was greater among (2-15 years of age) children, compared to (1 month-2 years of age) infants. CONCLUSIONS The present randomized controlled pilot study indicates that the tested automated closed-loop O2 titration technology was safe and yielded improved oxygen parameters among spontaneously breathing children. Based on our pilot data, a full randomized controlled trial will be required to verify the potential clinical benefits.
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Affiliation(s)
- Jean-Michel Roué
- Department of Pediatrics, Brest University Hospital, Brest, France
| | - Juliette Delpeut
- Department of Pediatrics, Brest University Hospital, Brest, France
| | - Alix d'Hennezel
- Department of Pediatrics, Brest University Hospital, Brest, France
| | - Tess Tierrie
- Department of Pediatrics, Brest University Hospital, Brest, France
| | - Audrey Barzic
- Department of Pediatrics, Brest University Hospital, Brest, France
| | - Erwan L'Her
- Department of Medical Intensive Care, Brest University Hospital, Brest, France
| | - Pierrick Cros
- Department of Pediatrics, Brest University Hospital, Brest, France
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15
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Bonafide CP, Xiao R, Brady PW, Landrigan CP, Brent C, Wolk CB, Bettencourt AP, McLeod L, Barg F, Beidas RS, Schondelmeyer A. Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen. JAMA 2020; 323:1467-1477. [PMID: 32315058 PMCID: PMC7175084 DOI: 10.1001/jama.2020.2998] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE US national guidelines discourage the use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen. OBJECTIVE Measure continuous pulse oximetry use in children with bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS A multicenter cross-sectional study was performed in pediatric wards in 56 US and Canadian hospitals in the Pediatric Research in Inpatient Settings Network from December 1, 2018, through March 31, 2019. Participants included a convenience sample of patients aged 8 weeks through 23 months with bronchiolitis who were not receiving active supplemental oxygen administration. Patients with extreme prematurity, cyanotic congenital heart disease, pulmonary hypertension, home respiratory support, neuromuscular disease, immunodeficiency, or cancer were excluded. EXPOSURES Hospitalization with bronchiolitis without active supplemental oxygen administration. MAIN OUTCOMES AND MEASURES The primary outcome, receipt of continuous pulse oximetry, was measured using direct observation. Continuous pulse oximetry use percentages were risk standardized using the following variables: nighttime (11 pm to 7 am), age combined with preterm birth, time after weaning from supplemental oxygen or flow, apnea or cyanosis during the present illness, neurologic impairment, and presence of an enteral feeding tube. RESULTS The sample included 3612 patient observations in 33 freestanding children's hospitals, 14 children's hospitals within hospitals, and 9 community hospitals. In the sample, 59% were male, 56% were white, and 15% were black; 48% were aged 8 weeks through 5 months, 28% were aged 6 through 11 months, 16% were aged 12 through 17 months, and 9% were aged 18 through 23 months. The overall continuous pulse oximetry monitoring use percentage in these patients, none of whom were receiving any supplemental oxygen or nasal cannula flow, was 46% (95% CI, 40%-53%). Hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%. After risk standardization, use ranged from 6% to 82%. Intraclass correlation coefficient suggested that 27% (95% CI, 19%-36%) of observed variation was attributable to unmeasured hospital-level factors. CONCLUSIONS AND RELEVANCE In a convenience sample of children hospitalized with bronchiolitis who were not receiving active supplemental oxygen administration, monitoring with continuous pulse oximetry was frequent and varied widely among hospitals. Because of the apparent absence of a guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse.
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Affiliation(s)
- Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rui Xiao
- Perelman School of Medicine, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick W. Brady
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christopher P. Landrigan
- Division of General Pediatrics, Boston Children's Hospital, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Canita Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Courtney Benjamin Wolk
- Perelman School of Medicine, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Penn Implementation Science Center, University of Pennsylvania, Philadelphia
| | - Amanda P. Bettencourt
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
- National Clinician Scholars Program and TACTICAL Scholar, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Lisa McLeod
- Department of Pediatrics, Children’s Hospital Colorado, Denver
- Array BioPharma, Boulder, Colorado
| | - Frances Barg
- Perelman School of Medicine, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia
| | - Rinad S. Beidas
- Perelman School of Medicine, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Penn Implementation Science Center, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
| | - Amanda Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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16
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Rees CA, Monuteaux MC, Raphael JL, Michelson KA. Disparities in Pediatric Mortality by Neighborhood Income in United States Emergency Departments. J Pediatr 2020; 219:209-215.e3. [PMID: 31610934 DOI: 10.1016/j.jpeds.2019.09.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/03/2019] [Accepted: 09/10/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate emergency department (ED) pediatric mortality by patient neighborhood income. STUDY DESIGN We calculated the incidence of ED pediatric mortality via a cross-sectional study of children <18 years who died in an ED using the Nationwide Emergency Department Sample and US Census from 2012 to 2016. The main exposure was median income for the patient's zip code tabulation area quartile. To determine factors associated with ED mortality, we modeled mortality using negative binomial regression. We used an interaction term between neighborhood income and insurance type to evaluate their relationship to mortality. RESULTS There were 64 893 ED deaths during the study period (incidence 17.3 per 100 000 person-years). The incidence of ED mortality increased with decreasing neighborhood income: compared with the wealthiest income quartile, the poorest, second, and third quartiles had adjusted incidence rate ratios (aIRRs) of 1.79 (95% CI 1.63-1.96), 1.42 (95% CI 1.29-1.55), and 1.23 (95% CI 1.12-1.36), respectively. The incidence of ED mortality was greater among uninsured children (aIRR 4.96, 95% CI 4.55-5.41) and publicly insured children (aIRR 2.69, 95% CI 2.51-2.88) compared with privately insured children. The interaction term showed no consistent relationship between neighborhood income and insurance with ED mortality. CONCLUSIONS Children from poorer neighborhoods have greater ED mortality rates than children from greater-income neighborhoods. Improved access to health insurance in the US may lead to reduced pediatric mortality, as ED mortality was greatest in uninsured children. Development of interventions to improve upstream determinants of health that contribute to ED mortality are needed.
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Affiliation(s)
- Chris A Rees
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jean L Raphael
- Center for Child Health Policy and Advocacy, Baylor College of Medicine, Houston, TX
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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17
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Gill PJ, Parkin P, Mahant S. Parenteral versus enteral fluid therapy for children hospitalised with bronchiolitis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Peter J Gill
- The Hospital for Sick Children; Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics; University of Toronto 555 University Ave Toronto ON Canada M5G 1X8
- University of Toronto; Department of Pediatrics, Faculty of Medicine; Toronto Ontario Canada
- SickKids Research Institute; Child Health Evaluative Sciences; Toronto Ontario Canada
- University of Toronto; Institute for Health Policy, Management and Evaluation; Toronto Ontario Canada
| | - Patricia Parkin
- The Hospital for Sick Children; Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics; University of Toronto 555 University Ave Toronto ON Canada M5G 1X8
- University of Toronto; Department of Pediatrics, Faculty of Medicine; Toronto Ontario Canada
- SickKids Research Institute; Child Health Evaluative Sciences; Toronto Ontario Canada
- University of Toronto; Institute for Health Policy, Management and Evaluation; Toronto Ontario Canada
| | - Sanjay Mahant
- The Hospital for Sick Children; Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics; University of Toronto 555 University Ave Toronto ON Canada M5G 1X8
- University of Toronto; Department of Pediatrics, Faculty of Medicine; Toronto Ontario Canada
- SickKids Research Institute; Child Health Evaluative Sciences; Toronto Ontario Canada
- University of Toronto; Institute for Health Policy, Management and Evaluation; Toronto Ontario Canada
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