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Cecil CA, Dziorny AC, Hall M, Kane JM, Kohne J, Olszewski AE, Rogerson CM, Slain KN, Toomey V, Goodman DM, Heneghan JA. Low-Resource Hospital Days for Children Following New Tracheostomy. Pediatrics 2024; 154:e2023064920. [PMID: 39113630 DOI: 10.1542/peds.2023-064920] [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: 11/05/2023] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 09/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Children with new tracheostomy and invasive mechanical ventilation (IMV) require transitional care involving caregiver education and nursing support. To better understand hospital resource use during this transition, our study aimed to: (1) define and characterize low-resource days (LRDs) for this population and (2) identify factors associated with LRD occurrence. METHODS This retrospective cohort analysis included children ≤21 years with new tracheostomy and IMV dependence admitted to an ICU from 2017 to 2022 using the Pediatric Health Information System database. A LRD was defined as a post tracheostomy day that accrued nonroom charges <10% of each patient's accrued nonroom charges on postoperative day 1. Factors associated with LRDs were analyzed using negative binomial regression. RESULTS Among 4048 children, median post tracheostomy stay was 69 days (interquartile range 34-127.5). LRDs were common: 38.6% and 16.4% experienced ≥1 and ≥7 LRDs, respectively. Younger age at tracheostomy (0-7 days rate ratio [RR] 2.42 [1.67-3.51]; 8-28 days RR 1.8 (1.2-2.69) versus 29-365 days; Asian race (RR 1.5 [1.04-2.16]); early tracheostomy (0-7 days RR 1.56 [1.2-2.04]), and longer post tracheostomy hospitalizations (31-60 days RR 1.85 [1.44-2.36]; 61-90 days RR 2.14 [1.58-2.91]; >90 days RR 2.21 [1.71-2.86]) were associated with more LRDs. CONCLUSIONS Approximately 1 in 6 children experienced ≥7 LRDs. Younger age, early tracheostomy, Asian race, and longer hospital stays were associated with increased risk of LRDs. Understanding the postacute phase, including bed utilization, serves as an archetype to explore care models for children with IMV dependence.
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Affiliation(s)
- Cara A Cecil
- Ann and Robert H. Lurie Children's Hospital of Chicago; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adam C Dziorny
- School of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Jason M Kane
- Pritzker School of Medicine, University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Joseph Kohne
- CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Aleksandra E Olszewski
- Ann and Robert H. Lurie Children's Hospital of Chicago; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Colin M Rogerson
- Division of Critical Care, Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Katherine N Slain
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Vanessa Toomey
- Children's Hospital Los Angeles; University of Southern California Keck School of Medicine, Los Angeles, California
| | - Denise M Goodman
- Ann and Robert H. Lurie Children's Hospital of Chicago; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julia A Heneghan
- University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
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Vermilion P, Boss R. Pediatric Perspectives on Palliative Care in the Neurocritical Care Unit. Neurocrit Care 2024:10.1007/s12028-024-02076-1. [PMID: 39138717 DOI: 10.1007/s12028-024-02076-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 07/09/2024] [Indexed: 08/15/2024]
Abstract
Pediatric neurocritical care teams care for patients and families facing the potential for significant neurologic impairment and high mortality. Such admissions are often marked by significant prognostic uncertainty, high levels of parental emotional overload, and multiple potentially life-altering decision points. In addition to clinical acumen, families desire clear and consistent communication, supported decision-making, a multidisciplinary approach to psychosocial supports throughout an admission, and comprehensive bereavement support after a death. Distinct from their adult counterparts, pediatric providers care for a broader set of rare diagnoses with limited prognostic information. Decision-making requires its own ethical framework, with substitutive judgment giving way to the best interest standard as well as "good parent" narratives. When a child dies, bereavement support is often needed for the broader community. There will always be a role for specialist palliative care consultation in the pediatric neurocritical care unit, but the care of every patient and family will be well served by improving these primary palliative care skills.
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Affiliation(s)
- Paul Vermilion
- Department of Medicine, Pediatrics, and Neurology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 687 , Rochester, NY, USA.
| | - Renee Boss
- Department of Pediatric Palliative Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Zampoli M, Booth J, Gray DM, Vanker A. Home ventilation in low resource settings: Learning to do more, with less. Pediatr Pulmonol 2024; 59:2180-2189. [PMID: 38050799 DOI: 10.1002/ppul.26802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 12/06/2023]
Abstract
Long-term ventilation (LTV) in children at home, especially invasive ventilation, is not widely available nor practised in low-resource settings (LRS). Barriers to providing LTV include underdeveloped pediatric critical care services, limited expertise in pediatric LTV, limited capacity to screen for sleep-disordered breathing (SDB) and high cost of LTV equipment and consumables. Additional challenges encountered in LRS may be unreliable electricity supply and difficult socioeconomic conditions. Where LTV at home has been successfully implemented, caregivers and families in LRS must often take full responsibility for their child's care as professional home-based nursing care is scarce. Selecting suitable children and families to offer LTV in LRS may therefore face difficult ethical decisions when families are disempowered or incapable of providing 24-h care at home. Early caregiver participation and hands-on training in tracheostomy care and LTV equipment is key to success, irrespective of the caregiver's level of education. The use of overnight oximetry, mobile phone technology, spirometry, and clinical evaluation are simple tools that can aid recognition and monitoring of children needing LTV. As children survive longer supported by LTV, engaging with adult services at an early stage is important to ensure suitable pathways for transition to adult care are in place. Building capacity and expertise in pediatric LTV in LRS requires targeted training of health professionals in related disciplines and advocacy to policymakers and funders that LTV in appropriately selected circumstances is worthwhile, life-changing, and cost-saving.
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Affiliation(s)
- Marco Zampoli
- Department of Pediatrics and Child Health, Division of Pediatric Pulmonology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Jane Booth
- Department of Pediatrics and Child Health, The Harry Crossley Children's Nursing Development Unit, University of Cape Town, Cape Town, South Africa
| | - Diane M Gray
- Department of Pediatrics and Child Health, Division of Pediatric Pulmonology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Aneesa Vanker
- Department of Pediatrics and Child Health, Division of Pediatric Pulmonology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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Agarwal A, Manimtim WM, Alexiou S, Abman SH, Akangire G, Aoyama BC, Austin ED, Baker CD, Bansal M, Bauer SE, Cristea AI, Dawson SK, Fierro JL, Hayden LP, Henningfeld JK, Kaslow JA, Lai KV, Levin JC, McKinney RL, Miller AN, Nelin LD, Popova AP, Siddaiah R, Tracy MC, Villafranco NM, McGrath-Morrow SA, Collaco JM. Factors associated with liberation from home mechanical ventilation and tracheostomy decannulation in infants and children with severe bronchopulmonary dysplasia. J Perinatol 2024:10.1038/s41372-024-02078-z. [PMID: 39085436 DOI: 10.1038/s41372-024-02078-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 06/21/2024] [Accepted: 07/24/2024] [Indexed: 08/02/2024]
Abstract
OBJECTIVE To identify factors associated with the timing of ventilator liberation and tracheostomy decannulation among infants with severe bronchopulmonary dysplasia (sBPD) who required chronic outpatient invasive ventilation. STUDY DESIGN Multicenter retrospective study of 154 infants with sBPD on outpatient ventilators. Factors associated with ventilator liberation and decannulation were identified using Cox regression models and multilevel survival models. RESULTS Ventilation liberation and decannulation occurred at median ages of 27 and 49 months, respectively. Older age at transition to a portable ventilator and at discharge, higher positive end expiratory pressure, and multiple respiratory readmissions were associated with delayed ventilator liberation. Surgical management of gastroesophageal reflux was associated with later decannulation. CONCLUSIONS Ventilator liberation timing was impacted by longer initial admissions and higher ventilator pressure support needs, whereas decannulation timing was associated with more aggressive reflux management. Variation in the timing of events was primarily due to individual-level factors, rather than center-level factors.
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Affiliation(s)
- Amit Agarwal
- Division of Pulmonary Medicine, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Winston M Manimtim
- Division of Neonatology, Children's Mercy-Kansas City and University of Missouri Kansas City School of Medicine, Kansas, MO, USA
| | - Stamatia Alexiou
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA
| | - Steven H Abman
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gangaram Akangire
- Division of Neonatology, Children's Mercy-Kansas City and University of Missouri Kansas City School of Medicine, Kansas, MO, USA
| | - Brianna C Aoyama
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Eric D Austin
- Pulmonary Medicine, Vanderbilt University and Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher D Baker
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Manvi Bansal
- Pulmonology and Sleep Medicine, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Sarah E Bauer
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Children's Hospital and Indiana University, Indianapolis, IN, USA
| | - A Ioana Cristea
- Division of Pediatric Pulmonology, Allergy and Sleep Medicine, Riley Children's Hospital and Indiana University, Indianapolis, IN, USA
| | - Sara K Dawson
- Department of Pediatrics, Medical College of Wisconsin Milwaukee, Milwaukee, WI, USA
| | - Julie L Fierro
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA
| | - Lystra P Hayden
- Division of Pulmonary Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Jacob A Kaslow
- Pulmonary Medicine, Vanderbilt University and Vanderbilt University Medical Center, Nashville, TN, USA
| | - Khanh V Lai
- Division of Pediatric Pulmonary and Sleep Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jonathan C Levin
- Division of Pulmonary Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Robin L McKinney
- Department of Pediatrics, Brown University School of Medicine, Providence, RI, USA
| | - Audrey N Miller
- Division of Neonatology, Nationwide Children's Hospital and Ohio State University, Columbus, OH, USA
| | - Leif D Nelin
- Division of Neonatology, Nationwide Children's Hospital and Ohio State University, Columbus, OH, USA
| | - Antonia P Popova
- Pediatric Pulmonology, University of Michigan, Ann Arbor, MI, USA
| | - Roopa Siddaiah
- Pediatric Pulmonology, Penn State Health, Hershey, PA, USA
| | - Michael C Tracy
- Division of Pediatric Pulmonary, Asthma and Sleep Medicine, Stanford University, Stanford, CA, USA
| | - Natalie M Villafranco
- Pulmonary Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Sharon A McGrath-Morrow
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University, Baltimore, MD, USA
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High MS, Lynch E, Sobotka SA. Parent perspectives on education to support hospital discharge for children with invasive mechanical ventilation. J Pediatr Nurs 2024:S0882-5963(24)00264-1. [PMID: 39025713 DOI: 10.1016/j.pedn.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Children with invasive mechanical ventilation (IMV) often live at home, but for safety, parents must be prepared to assume primary responsibility for all aspects of their child's medically complex care. Prior studies have described discharge education programs, however often without perspectives of parents with lived experience transitioning home. PURPOSE To describe parent perspectives on hospital-based education for discharging home a child with IMV. DESIGN AND METHODS A secondary qualitative analysis of 23 parent interviews between February 2019 to January 2022 on topics related to caring for a child with IMV. Each interview was coded independently and discussed to consensus. Data from codes related to parent education and training were analyzed to identify themes and sub-themes. RESULTS Parents of 23 children with IMV participated in the primary interviews a month after hospital discharge. Four main themes in the secondary dataset were identified: (1) Training context: The hospital can be a stressful and difficult learning environment; (2) Training characteristics: Parents receive thorough training from interdisciplinary providers; (3) Learner characteristics: Parents are motivated learners who independently seek out knowledge; (4) Post-discharge education: Parents gain confidence in their expertise after navigating an emergency. CONCLUSIONS Parents who have transitioned from hospital-to-home describe sufficiently detailed hospital-based education; many felt trained as capably as nurses. However, parents experienced in-hospital training as inflexible and stressful. PRACTICE IMPLICATIONS Parents of children with IMV are eager learners but parent education is not always family-centered. Reforming the hospital learning environment to match parent needs will improve family experiences and training.
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Affiliation(s)
- Michelle S High
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; College of Nursing, Rush University, Chicago, IL, USA.
| | - Emma Lynch
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, University of Chicago, Chicago, IL, USA
| | - Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, University of Chicago, Chicago, IL, USA
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Koob C, Griffin SF, Stuenkel M, Cartmell K, Rennert L, Sease K. Bridging the gaps in pediatric complex healthcare: the case for home nursing care among children with medical complexity. BMC Health Serv Res 2024; 24:814. [PMID: 39010079 PMCID: PMC11251302 DOI: 10.1186/s12913-024-11235-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 06/23/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Children with medical complexity (CMC) comprise < 1% of the pediatric population, but account for nearly one-third of healthcare expenditures. Further, while CMC account for up to 80% of pediatric inpatient hospital costs, only 2% of Medicaid spending is attributed to home healthcare. As a result, the current health system heavily relies on family caregivers to fill existing care gaps. This study aimed to: (1) examine factors associated with hospital admissions among CMC and (2) contextualize the potential for home nursing care to improve outcomes among CMC and their families in South Carolina (SC). METHODS This mixed-methods study was conducted among CMC, their family caregivers, and physicians in SC. Electronic health records data from a primary care clinic within a large health system (7/1/2022-6/30/2023) was analyzed. Logistic regression examined factors associated with hospitalizations among CMC. In-depth interviews (N = 15) were conducted among physicians and caregivers of CMC statewide. Patient-level quantitative data is triangulated with conceptual findings from interviews. RESULTS Overall, 39.87% of CMC experienced ≥ 1 hospitalization in the past 12 months. CMC with higher hospitalization risk were dependent on respiratory or neurological/neuromuscular medical devices, not non-Hispanic White, and demonstrated higher healthcare utilization. Interview findings contextualized efforts to reduce hospitalizations, and suggested adaptations related to capacity and willingness to provide complex care for CMC and their families. CONCLUSIONS Findings may inform multi-level solutions for accessible, high-quality home nursing care among CMC and their families. Providers may learn from caregivers' insight to emphasize family-centered care practices, acknowledging time and financial constraints while optimizing the quality of medical care provided in the home.
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Affiliation(s)
- Caitlin Koob
- Department of Public Health Sciences, Clemson University, 501 Epsilon Zeta Dr. (Edwards Hall), Clemson, SC, 29634, USA.
| | - Sarah F Griffin
- Department of Public Health Sciences, Clemson University, 501 Epsilon Zeta Dr. (Edwards Hall), Clemson, SC, 29634, USA
| | | | - Kathleen Cartmell
- Department of Public Health Sciences, Clemson University, 501 Epsilon Zeta Dr. (Edwards Hall), Clemson, SC, 29634, USA
| | - Lior Rennert
- Department of Public Health Sciences, Clemson University, 501 Epsilon Zeta Dr. (Edwards Hall), Clemson, SC, 29634, USA
| | - Kerry Sease
- Prisma Health (Bradshaw Institute for Community Child Health and Advocacy), 255 Enterprise Blvd #110, Greenville, SC, 29615, USA
- Furman University, Greenville, SC, 29613, USA
- Executive Director of the Institute for Advancement of Community Health, Greenville, SC, 29613, USA
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Kodiak T, Quinn M, Zekas L. Current state of home health in children with medical complexity. J Pediatr Nurs 2024; 77:180-182. [PMID: 38531175 DOI: 10.1016/j.pedn.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Home health services are a right for children in the US, but higher survival rates of extremely preterm infants have led to an increase in children with medical complexity (CMC) and therefore an increased demand for home health services. Unfortunately, an adequately trained and compensated workforce to support medially complex children at home does not exist. METHODS After identifying the existing research, common themes were identified. This article was written to give an overview of these themes and highlight specific supporting data. RESULTS A lack of resources in the home health arena and the financial barriers that accompany them, as well as the clear impact this issue has on the health and well-being of families and caregivers, were frequently present in the literature. CONCLUSIONS Reasonable next steps for research and advocacy include a focus on recruitment and retention of home health nurses, as well as training specific to the level of skill required to adequately care for CMC. Further research is needed, as in our search we found several unexplored, unassessed avenues that could help health care professionals understand the problem more fully. These steps are necessary if we want CMC to live the healthiest life available to them.
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Affiliation(s)
- Teresa Kodiak
- Ann and Robert H. Lurie Children's Hospital of Chicago, USA.
| | - Megan Quinn
- Ann and Robert H. Lurie Children's Hospital of Chicago, USA
| | - Linda Zekas
- Ann and Robert H. Lurie Children's Hospital of Chicago, USA
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Millar K, Rodd C, Rempel G, Cohen E, Sibley KM, Garland A. The Clinical Definition of Children With Medical Complexity: A Modified Delphi Study. Pediatrics 2024; 153:e2023064556. [PMID: 38804054 DOI: 10.1542/peds.2023-064556] [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: 10/04/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Children with medical complexity (CMC) comprise a subgroup of children with severe chronic diseases. A conceptual definition for CMC has been formulated, but there is no agreement on criteria to fulfill each of the 4 proposed domains: diagnostic conditions, functional limitations, health care use, and family-identified needs. Our objective with this study was to identify a standardized definition of CMC. METHODS Through a scoping review of the CMC literature, we identified potential criteria to fulfill each domain. These were incorporated into an electronic survey that was completed by a geographic and professionally varied panel of 81 American and Canadian respondents with expertise in managing CMC (response rate 70%) as part of a 4-iteration Delphi procedure. Respondents were asked to vote for the inclusion of each criterion in the definition, and for those with quantitative components (eg, hospitalization rates), to generate a consensus threshold value for meeting that criterion. The final criteria were analyzed by a committee and collapsed when situations of redundancy arose. RESULTS Of 1411 studies considered, 132 informed 55 criteria for the initial survey, which was presented to 81 respondents. Consensus for inclusion was reached on 48 criteria and for exclusion on 1 criterion. The committee collapsed those 48 criteria into 39 final criteria, 1 for diagnostic conditions, 2 for functional limitations, 13 for health care use, and 23 for family needs. CONCLUSIONS These results represent the first consensus-based, standardized definition of CMC. Standardized identification is needed to advance understanding of their epidemiology and outcomes, as well as to rigorously study treatment strategies and care models.
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Affiliation(s)
| | | | | | - Eyal Cohen
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | - Allan Garland
- Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Abstract
OBJECTIVES To identify and geolocate pediatric post-acute care (PAC) facilities in the United States. DESIGN Cross-sectional survey using both online resources and telephone inquiry. SETTING All 50 U.S. states surveyed from June 2022 to May 2023. Care sites identified via state regulatory agencies and the Centers for Medicare & Medicaid Services. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Number, size, and type of facility, scope of practice, and type of care provided. One thousand three hundred fifty-five facilities were surveyed; of these, 18.6% (252/1355) were pediatric-specific units or adult facilities accepting some pediatric patients. There were 109 pediatric-specific facilities identified within 39 U.S. states. Of these, 38 were freestanding with all accepting children with tracheostomies, 97.4% (37/38) accepting those requiring mechanical ventilation via tracheostomy, and 81.6% (31/38) accepting those requiring parenteral nutrition. The remaining 71 facilities were adult facilities with embedded pediatric units or children's hospitals with 88.7% (63/71), 54.9% (39/71), and 54.9% (39/71), accepting tracheostomies, mechanical ventilation via tracheostomy, and parenteral nutrition, respectively. Eleven states lacked any pediatric-specific PAC units or facilities. CONCLUSIONS The distribution of pediatric PAC is sparse and uneven across the United States. We present an interactive map and database describing these facilities. These data offer a starting point for exploring the consequences of pediatric PAC supply.
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Affiliation(s)
- Nadine Straka
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Harvard University, Boston, MA
| | - Urbano L França
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Harvard University, Boston, MA
| | - Jennifer D Franks
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Michael L McManus
- Division of Critical Care, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Harvard University, Boston, MA
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Sobotka SA, Lynch E, Liao C, Graham RJ, Msall ME. Autism and neurodevelopmental disability risks in children with tracheostomies and ventilators. Pediatr Pulmonol 2024; 59:1380-1387. [PMID: 38426806 DOI: 10.1002/ppul.26921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/31/2024] [Accepted: 02/06/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND/OBJECTIVE Infants who survive prematurity and other critical illnesses and require continued invasive mechanical ventilation (IMV) postdischarge (at home) are at high risk of developmental delays and disabilities. Studies of extremely preterm cohorts (<28-week gestation) demonstrate rates of 25% for intellectual disability (ID) and 7% for autism spectrum disorder (ASD). Rates of ASD and ID in children with IMV are unknown. This study aimed to determine neurodevelopmental disability risk in a cohort of children with postdischarge IMV. DESIGN/METHODS A consecutive series of children with IMV were assessed 1 month, 6 months, and 1 year after discharge. Cognitive, social, and communicative domains were assessed by a Developmental and Behavioral Pediatrician using (1) clinical adaptive test/clinical linguistic and auditory milestone scale (CAT/CLAMS) of the capute scales; (2) pediatric evaluation of disability inventory computer adaptive test (PEDI-CAT); and (3) modified checklist for autism in toddlers, revised (MCHAT-R). Red flag signs and symptoms of ASD using DSM-V criteria were noted. Longitudinal testing was reviewed. Expert consensus impressions of evolving ASD and/or ID were determined. RESULTS Eighteen children were followed for 1 year; at 1 year, the median age (range) was 23 (17-42) months. Children were 44% male, 33% non-Hispanic White, 39% non-Hispanic Black, and 28% Hispanic. Fifteen (83%) children were prematurity survivors. Median (range) developmental quotients (DQs): full-scale DQ 59 (11-86), CAT DQ 66.5 (8-96), and CLAMS DQ 49.5 (13-100). Twelve (67%) children were highly suspicious for ASD and/or evolving ID. CONCLUSIONS/SIGNIFICANCE This cohort of children with at-home IMV demonstrates a higher risk of ASD and ID than prior premature cohorts. Larger investigations with longer follow-up are needed.
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Affiliation(s)
- Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Emma Lynch
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Chuanhong Liao
- Department of Public Health Sciences, The University of Chicago, Chicago, Illinois, USA
| | - Robert J Graham
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael E Msall
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
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11
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Bhargava A, Khedkar K. Chronic Constipation Unmasking as Hirschsprung Disease in a Preadolescent: Delayed Presentation or Delayed Diagnosis? Cureus 2024; 16:e60315. [PMID: 38883048 PMCID: PMC11177269 DOI: 10.7759/cureus.60315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 05/14/2024] [Indexed: 06/18/2024] Open
Abstract
Hirschsprung disease, a rare genetic disorder affecting the enteric nervous system, is characterized by the absence of ganglion cells in the myenteric plexus. Typically identified in neonates due to the failure to pass meconium, diagnosis beyond the first year of life is considered delayed. Common clinical manifestations in children with late-onset Hirschsprung disease include abdominal distension, abdominal pain, vomiting, fever, and abnormal bowel sounds. Sigmoid volvulus, though uncommon, can complicate Hirschsprung disease, potentially leading to misdiagnosis and severe complications such as intestinal perforation, hemorrhage, sepsis, and even mortality. Non-surgical interventions such as antibiotic therapy, intestinal decompression, and fluid resuscitation are preferred initial treatments to stabilize the patient. This case involves a 9-year-old boy who has presented with abdominal distension since birth and a lengthy history of irregular bowel habits. The diagnosis of Hirschsprung disease was confirmed at our institution, and the patient underwent a two-stage repair procedure, which was completed without any intraoperative or postoperative complications. The patient experienced an uneventful recovery, was discharged with stable vital signs, and regained normal bowel function. This case highlights the challenges of delayed diagnosis at nine years and underscores the importance of prompt management.
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Affiliation(s)
- Abhilasha Bhargava
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Kiran Khedkar
- Pediatric Surgery, All India Institute of Medical Sciences, Nagpur, IND
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Geyer D, Vessey JA. Caring for children with medical complexity at home: An integrative review. J Pediatr Nurs 2024; 76:167-175. [PMID: 38412708 DOI: 10.1016/j.pedn.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/28/2023] [Accepted: 02/19/2024] [Indexed: 02/29/2024]
Abstract
PROBLEM Despite reporting significant systemic barriers to providing care, burden among parental caregivers of children with medical complexity (CMC) is often attributed to stressors related to disease management. The relationship between parental caregiver burden and systemic barriers within the healthcare bureaucracy, as defined by Ray's Theory of Bureaucratic Caring (BCT), has not been explored. The purpose of this integrative review was to examine which elements of the bureaucratic healthcare system are contributing to burden among parental caregivers of CMC living at home. ELIGIBILITY CRITERIA Refereed research articles related to the experiences of parental caregivers of CMC living in the United States published after 2014. SAMPLE 1967 articles were obtained on initial literature search. Using the PRISMA algorithm, ten articles published between 2018 and 2022 were ultimately selected for appraisal. RESULTS Parental caregiver burden was consistently attributed to barriers and gaps among social-cultural, physical, political, legal, economic, technological, and educational elements of the bureaucratic healthcare system. CONCLUSIONS Weaknesses across the bureaucratic elements of the healthcare system prevent CMC from consistently receiving necessary care which in turn, contribute to feelings of burden among their parental caregivers. Efforts to alleviate burden experienced by parental caregivers should focus on addressing gaps within the healthcare bureaucracy. IMPLICATIONS Nurses are well-positioned to address these gaps through clinical work, advocacy, and research. Future research should further examine the appropriateness of using BCT to better understand the implications of systems-level weaknesses on parental caregiver burden. Parental caregivers of CMC should be closely involved in this process.
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Affiliation(s)
- David Geyer
- William F. Connell School of Nursing, Boston College, MA, USA.
| | - Judith A Vessey
- William F. Connell School of Nursing, Boston College, MA, USA; Medical, Surgical and Behavioral Health Programs, Boston Children's Hospital, MA, USA
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13
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Sobotka SA, Lynch E, Golden SLS, Nageswaran S. Home Health Nursing Agencies' Services for Children With Medical Complexity: Parent and Nurse Perspectives. Acad Pediatr 2024; 24:477-485. [PMID: 38278479 DOI: 10.1016/j.acap.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/16/2024] [Accepted: 01/21/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE Many children with medical complexity (CMC) require the services of home health nurses (HHNs). Home health agencies (HHAs) hire, train, and manage nurses. For children to flourish, families, nurses, and HHAs must establish successful working relationships. Our objective was to understand the perspectives of parents and nurses about HHAs. METHODS In Illinois (IL) from 2019 to 2022, HHNs for and parents of children with invasive mechanical ventilation were interviewed. In North Carolina (NC) from 2012 to 2013, parents of CMC were interviewed, and from 2013 to 2014 HHNs participated in focus groups. Each dataset was initially analyzed separately for main themes relating to HHAs. Using collaborative thematic analysis, we determined themes common across datasets. RESULTS In IL, 23 mothers, 12 fathers, and 20 nurses were interviewed. In NC, 19 mothers, 6 fathers, and 1 grandmother were interviewed; and 4 focus groups of 18 nurses were conducted. Four common themes were identified. 1) HHAs do not have a uniform process for hiring and assigning nurses to cases. 2) HHAs have marked variability in training offered to nurses. 3) Shift scheduling, notifications, and communications with the HHAs frustrate parents and nurses. 4) Nurses and parents have little allegiance to specific HHAs; they frequently change agencies or work with several simultaneously. CONCLUSIONS Parents and nurses perceive practices for hiring, training, and staffing as inconsistent, and experience communication challenges. HHA-level problems may contribute to issues with HHN retention and complicate the lives of the families of CMC. Further research about this critical health care sector is needed.
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Affiliation(s)
- Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics (SA Sobotka, E Lynch), The University of Chicago, Chicago, IL.
| | - Emma Lynch
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics (SA Sobotka, E Lynch), The University of Chicago, Chicago, IL
| | | | - Savithri Nageswaran
- Department of Pediatrics (S Nageswaran), Wake Forest University School of Medicine, Winston-Salem, NC
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14
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Song IG, Kim YS, Kim MS, Lee JW, Cho YM, Lim Y, Kwon SK, Suh DI, Park JD. Healthcare service use and medical outcomes of tracheostomy-dependent children: a nationwide study. BMJ Paediatr Open 2024; 8:e002377. [PMID: 38508660 PMCID: PMC10952918 DOI: 10.1136/bmjpo-2023-002377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/10/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Despite the rising trend of tracheostomies in children, there is a lack of comprehensive resources for families to navigate the challenges of living with a tracheostomy, emphasising the need for evidence-based support in understanding postoperative care and long-term adjustments. This study aimed to examine the pattern of using healthcare services and nationwide medical outcomes in children who underwent a tracheotomy before the age of 2 years. METHODS This retrospective study used the National Health Insurance System database from 2008 to 2016 and included all children codified with tracheotomy procedure codes before their second birthday. Healthcare utilisation, such as medical costs, number of hospital visits, home healthcare nursing and medical diagnoses on readmission, in the first 2 years after tracheotomy was evaluated. Multivariable logistic regression analysis was used to determine the factors affecting mortality. RESULTS In total, 813 patients were included in this study. Their use of healthcare services and the accompanying expenses were higher than the national medians for similar age groups; however, both metrics decreased in the second year. The major causes of admission within 2 years of surgery were respiratory and neurological diseases. The mortality rate within 2 years was 37.8%. Higher risks of mortality were associated with having two or more complex chronic conditions. Use of home healthcare nursing services was associated with a lower mortality risk. CONCLUSION Paediatric patients with more complex chronic conditions tended to have higher mortality rates within 2 years after surgery. However, receiving home healthcare nursing was significantly associated with a reduced risk of death. Many causes of hospitalisation may be preventable with education and supportive care. Therefore, further research for establishing an integrated care system for these patients and their caregivers is required.
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Affiliation(s)
- In Gyu Song
- Pediatrics, Yonsei University College of Medicine, Seodaemun-gu, Korea (the Republic of)
| | - You Sun Kim
- Department of Paediatrics, National Medical Center, Jung, Korea (the Republic of)
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Min Sun Kim
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
- Seoul National University Children's Hospital Integrated Care Center, Seoul, Korea (the Republic of)
| | - Ji Weon Lee
- Seoul National University Children's Hospital Integrated Care Center, Seoul, Korea (the Republic of)
| | - Yoon-Min Cho
- National Health Insurance Service, Wonju, Korea (the Republic of)
| | - Youna Lim
- Seoul National University, Gwanak-gu, Korea (the Republic of)
| | - Seong Keun Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Dong In Suh
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - June Dong Park
- Department of Paediatrics, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
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15
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Huang L, Saint Onge JM. Differences in Healthcare Utilization in Children with Developmental Disabilities Following Value-Based Care Coordination Policies. J Healthc Manag 2024; 69:140-155. [PMID: 38467027 DOI: 10.1097/jhm-d-23-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
GOAL To address healthcare spending growth, coordinate care, and improve primary care utilization, a majority of states in the United States have adopted value-based care coordination programs. The objective of this study was to identify changes in national healthcare utilization for children with developmental disabilities (DDs), a high-cost and high-need population, following the broad adoption of value-based care coordination policies. METHODS This retrospective study included 9,109 children with DDs and used data from 2002-2018 Medical Expenditure Panel Survey. We applied an interrupted time series design approach to compare pre- and post-Affordable Care Act (ACA) care coordination policies concerning healthcare utilization outcomes, including outpatient visits, home provider days, emergency department (ED) visits, inpatient discharge, and inpatient nights of stay. PRINCIPAL FINDINGS We found statistically significant increases in low-cost care post-ACA, including outpatient visits (5% higher, p < .001) and home provider days (11% higher, p < .001). The study findings also showed a statistically significant increase in inpatient nights of stay post-ACA (4% higher, p = .001). There were no changes in the number of ED and inpatient visits. Overall, broad implementation of care coordination programs was associated with increased utilization of low-cost care without increases in the number of high-cost ED and inpatient visits for children with DDs. Our study also found changes in population composition among children with DDs post-ACA, including increases in Hispanic (16.9% post-ACA vs. 13.4% pre-ACA, p = .006) and non-Hispanic multiracial children (9.1% post-ACA vs. 5.5% pre-ACA, p = .001), a decrease in non-Hispanic Whites (60.2% post-ACA vs. 68.6% pre-ACA, p = .001), more public-only insurance (44.3% post-ACA vs. 35.7% pre-ACA, p = .001), fewer children with DDs from middle-income families (27.4% post-ACA vs. 32.8% pre-ACA, p < .001), and more children with DDs from poor families (28.2% post-ACA vs. 25.1% pre-ACA, p = .043). PRACTICAL APPLICATIONS These findings highlight the importance of continued support for broad care coordination programs for U.S. children with DDs and potentially others with complex chronic conditions. Policymakers and healthcare leaders might consider improving care transitions from inpatient to community or home settings by overcoming barriers such as payment models and the lack of home care nurses who can manage complex chronic conditions. Healthcare leaders also need to understand and consider the changing population composition when implementing care coordination-related policies. This study provides data regarding trends in hospital and home care utilization and evidence of the effectiveness of care coordination policies before the COVID-19 interruption. These findings apply to current healthcare management because COVID-19 has incentivized home care, which may have a strong potential to minimize high-cost care for people with complex chronic conditions. More research is warranted to continue monitoring care coordination changes over a longer period.
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Affiliation(s)
| | - Jarron M Saint Onge
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas
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16
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Foster CC, Kwon S, Blakely C, Carter K, Sobotka SA, Goodman DM, Agrawal R, Brittan M. Paying Family Medical Caregivers for Children's Home Healthcare in Colorado: A Working Medicaid Model. J Pediatr 2023; 261:113347. [PMID: 36775189 PMCID: PMC10412725 DOI: 10.1016/j.jpeds.2022.12.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/06/2022] [Accepted: 12/26/2022] [Indexed: 02/12/2023]
Abstract
OBJECTIVE To compare the characteristics and healthcare use of children with medical complexity who receive paid certified nursing assistant (CNA) care by a family member (family CNA) and by a traditional nonfamily member (nonfamily CNA). STUDY DESIGN This was retrospective cohort study of children who received CNA care through Colorado's Medicaid paid family caregiving program between 2017 and 2019 by a home healthcare agency. We compared patient characteristics between the family CNA and nonfamily CNA groups. A multivariable Poisson regression model was used to compare hospitalization rates (days in the hospital per year), adjusting for patient age patient sex, nursing care, and complex chronic condition. RESULTS Of 861 patients, 79% (n = 680) received family CNA care and 21% (n = 181) received nonfamily CNA care. Patient demographics and hospitalization did not differ between the groups, although patients who had family CNAs were less likely to receive additional nursing-level care (42% vs 60%, P < .01). Family and nonfamily CNA caregivers had similar characteristics, except that family CNA caregivers had substantially better 3-year retention (82% vs 9%, P < .01) despite lower average hourly pay ($14.60 vs $17.60 per hour, P < .01). Hospitalizations were rare (<10% of patients). In the adjusted model, patients who received family CNA care experienced 1 more hospitalized day per year, compared with patients who received nonfamily CNA care (P < .001). CONCLUSIONS Paid family caregivers provided CAN-level care to children with medical complexity with a greater employee retention compared with nonfamily CNA caregivers, with marginally different hospitalization rates using a family-centered approach. This model may help address workforce shortages while also providing income to family caregivers.
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Affiliation(s)
- Carolyn C Foster
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL; Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.
| | - Soyang Kwon
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | | | - Kristin Carter
- Division of Palliative Care, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, The University of Chicago, Chicago, IL
| | - Denise M Goodman
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Rishi Agrawal
- Division of Hospital Based Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mark Brittan
- Section of Pediatric Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO; Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, CO
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17
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Widger K, Brennenstuhl S, Nelson KE, Seow H, Rapoport A, Siden H, Vadeboncoeur C, Gupta S, Tanuseputro P. Intensity of end-of-life care among children with life-threatening conditions: a national population-based observational study. BMC Pediatr 2023; 23:375. [PMID: 37488553 PMCID: PMC10364373 DOI: 10.1186/s12887-023-04186-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Children with life-threatening conditions frequently experience high intensity care at the end of life, though most of this research only focused on children with cancer. Some research suggests inequities in care provided based on age, disease type, socioeconomic status, and distance that the child lives from a tertiary hospital. We examined: 1) the prevalence of indicators of high intensity end-of-life care (e.g., hospital stays, intensive care unit [ICU] stays, death in ICU, use of cardiopulmonary resuscitation [CPR], use of mechanical ventilation) and 2) the association between demographic and diagnostic factors and each indicator for children with any life-threatening condition in Canada. METHODS We conducted a population-based retrospective cohort study using linked health administrative data to examine care provided in the last 14, 30, and 90 days of life to children who died between 3 months and 19 years of age from January 1, 2008 to December 31, 2014 from any underlying life-threatening medical condition. Logistic regression was used to model the association between demographic and diagnostic variables and each indicator of high intensity end-of-life care except number of hospital days where negative binomial regression was used. RESULTS Across 2435 child decedents, the most common diagnoses included neurology (51.1%), oncology (38.0%), and congenital illness (35.9%), with 50.9% of children having diagnoses in three or more categories. In the last 30 days of life, 42.5% (n = 1035) of the children had an ICU stay and 36.1% (n = 880) died in ICU. Children with cancer had lower odds of an ICU stay (OR = 0.47; 95% CI = 0.36-0.62) and ICU death (OR = 0.37; 95%CI = 0.28-0.50) than children with any other diagnoses. Children with 3 or more diagnoses (vs. 1 diagnosis) had higher odds of > 1 hospital stay in the last 30 days of life (OR = 2.08; 95%CI = 1.29-3.35). Living > 400 km (vs < 50 km) from a tertiary pediatric hospital was associated with higher odds of multiple hospitalizations (OR = 2.09; 95%CI = 1.33-3.33). CONCLUSION High intensity end of life care is prevalent in children who die from life threatening conditions, particularly those with a non-cancer diagnosis. Further research is needed to understand and identify opportunities to enhance care across disease groups.
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Affiliation(s)
- Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
- Hospital for Sick Children, Toronto, Canada.
| | - Sarah Brennenstuhl
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | | | | | - Adam Rapoport
- Hospital for Sick Children, Toronto, Canada
- Emily's House Children's Hospice, Toronto, Canada
| | - Harold Siden
- Canuck Place Children's Hospice, Vancouver, Canada
- British Columbia Children's Hospital, Vancouver, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Christina Vadeboncoeur
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
- CHEO, Ottawa, Canada
- Roger Neilson House, Ottawa, Canada
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18
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Curfman AL, Haycraft M, McSwain SD, Dooley M, Simpson KN. Implementation and Evaluation of a Wraparound Virtual Care Program for Children with Medical Complexity. Telemed J E Health 2023; 29:947-953. [PMID: 36355064 PMCID: PMC10277989 DOI: 10.1089/tmj.2022.0344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/11/2022] Open
Abstract
Objectives: Children and adolescents with medical complexity benefit from care coordination and specialized pediatric care, but many access barriers exist. We implemented a virtual wraparound model to support patients with medical complexity and their families and used an economic framework to measure outcomes. Methods: Children with medical complexity were identified and enrolled in a virtual complex care program with a dedicated multidisciplinary team, which provided care coordination, education, parental support, acute care triage, and virtual visits. A retrospective pre- and postanalysis of data obtained from the Hospital Industry Data Institute (HIDI) database measured inpatient, outpatient, and emergency department (ED) utilization and charges before implementation and during the 2-year program. Results: Eighty (n = 80) children were included in the economic evaluation, and 75 had sufficient data for analysis. Compared to the 12 months before enrollment, patients had a 35.3% reduction in hospitalizations (p = 0.0268), a 43.9% reduction in emergency visits (p = 0.0005), and a 16.9% reduction in overall charges (p = 0.1449). Parents expressed a high degree of satisfaction, with a 70% response rate and 90% satisfaction rate. Conclusions: We implemented a virtual care model to provide in-home support and care coordination for medically complex children and adolescents and used an economic framework to assess changes in utilization and cost. The program had high engagement rates and parent satisfaction, and a pre/postanalysis demonstrated statistically significant reduction in hospitalizations and ED visits for this high-cost population. Further economic evaluation is needed to determine sustainability of this model in a value-based payment system.
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Affiliation(s)
- Alison L. Curfman
- Mercy Clinic Department of Pediatrics, St. Louis, Missouri, USA
- Imagine Pediatrics, Nashville, Tennessee, USA
| | | | - S. David McSwain
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Mary Dooley
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kit N. Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina, USA
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19
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Foster C, Noreen P, Grage J, Kwon S, Hird-McCorry LP, Janus A, Davis MM, Goodman D, Laguna T. Predictors for invasive home mechanical ventilation duration in bronchopulmonary dysplasia. Pediatr Pulmonol 2023. [PMID: 37114844 DOI: 10.1002/ppul.26437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Children with bronchopulmonary dysplasia (BPD) who require invasive home mechanical ventilation (IHMV) are medically vulnerable and experience high caregiving and healthcare costs. Predictors for duration of IHMV in children with BPD remain unclear, which can make prognostication and decision-making challenging. METHODS A retrospective cohort study of children with BPD requiring IHMV was conducted from independent children's hospital records (2005-2021). The primary outcome was IHMV duration, defined as time from initial discharge home on IHMV until cessation of positive pressure ventilation (day and night). Two new variables were included: discharge age corrected for tracheostomy (DACT) (chronological age at discharge minus age at tracheostomy) and level of ventilator support at discharge (minute ventilation per kg per day). Univariable Cox regression was performed with variables of interest compared to IHMV duration. Significant nonlinear factors (p < 0.05) were included in the multivariable analysis. RESULTS One-hundred-and-nineteen patients used IHMV primarily for BPD. Patient median index hospitalization lasted 12 months (interquartile range [IQR] 8.0,14.4). Once home, half of the patients were weaned off IHMV by 36.0 months and 90% by 52.2 months. Being Hispanic/Latinx ethnicity (hazard ratio [HR] 0.14 (95% confidence interval [CI] 0.04, 0.53), p < 0.01) and having a higher DACT were associated with increased IHMV duration (HR 0.66 (CI 0.43, 0.98), p < 0.05). CONCLUSIONS Disparity in IHMV duration exists among patients using IHMV after prematurity. Prospective multisite studies that further investigate new analytic variables, such as DACT and level of ventilator support, and address standardization of IHMV care are needed to create more equitable IHMV management strategies.
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Affiliation(s)
- Carolyn Foster
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Digital Health, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Paige Noreen
- McGaw Medical Center, Northwestern University, Chicago, Illinois, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Jennifer Grage
- McGaw Medical Center, Northwestern University, Chicago, Illinois, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Soyang Kwon
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Lindsey P Hird-McCorry
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pulmonary Habilitation Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Angela Janus
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pulmonary Habilitation Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Matthew M Davis
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Departments of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Denise Goodman
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pulmonary Habilitation Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Theresa Laguna
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pulmonary Habilitation Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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20
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Pitch N, Davidson L, Mekhuri S, Patel R, Patel S, Ambreen M, Amin R. Exploring the experience of family caregivers of children with medical complexity during COVID-19: a qualitative study. BMC Pediatr 2023; 23:160. [PMID: 37024854 PMCID: PMC10077324 DOI: 10.1186/s12887-023-03944-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 03/06/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Children with medical complexity have been disproportionately impacted by the COVID-19 pandemic and the associated changes in healthcare delivery. The primary objective of this study was to gain a thorough understanding of the lived experiences of family caregivers of children with medical complexity during the pandemic. METHODS We conducted semi-structured interviews with family caregivers of children with medical complexity from a tertiary pediatric hospital. Interview questions focused on the aspects of caregiving for children with medical complexity, impact on caregiver mental and physical well-being, changes to daily life secondary to the pandemic, and experiences receiving care in the healthcare system. Interviews were conducted until thematic saturation was achieved. Interviews were audio recorded, deidentified, transcribed verbatim, coded and analyzed using content analysis. RESULTS Twelve semi-structured interviews were conducted. The interviews revealed three major themes and several associated subthemes: (1) experiences with the healthcare system amid the pandemic (lack of access to healthcare services and increased hospital restrictions, negative clinical interactions and communication breakdowns, virtual care use); (2) common challenges during the pandemic (financial strain, balancing multiple roles, inadequate homecare nursing); and (3) the pandemic's impact on family caregiver well-being (mental toll, physical toll). CONCLUSIONS Family caregivers of children with medical complexity experienced mental and physical burden due to the intense nature of their caregiving responsibilities that were exacerbated during the pandemic. Our results highlight key priorities for the development of effective interventions to support family caregivers and their children.
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Affiliation(s)
- Natalie Pitch
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, 4539 Hill Wing, 555 University Ave, Toronto, ON, M5G 1X8, Canada.
| | - Laura Davidson
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, 4539 Hill Wing, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Samantha Mekhuri
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, 4539 Hill Wing, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Richa Patel
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, 4539 Hill Wing, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Selvi Patel
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, 4539 Hill Wing, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Munazzah Ambreen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, 4539 Hill Wing, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, 4539 Hill Wing, 555 University Ave, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Child Health Evaluative Sciences (CHES) SickKids Research Institute, Toronto, ON, Canada
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21
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Akangire G, Lachica C, Noel-MacDonnell J, Begley A, Sampath V, Truog W, Manimtim W. Outcomes of infants with severe bronchopulmonary dysplasia who received tracheostomy and home ventilation. Pediatr Pulmonol 2023; 58:753-762. [PMID: 36377273 DOI: 10.1002/ppul.26248] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 11/02/2022] [Accepted: 11/13/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe the survival rate, timing of liberation from the ventilator, and factors favorable for decannulation among infants with severe bronchopulmonary dysplasia (sBPD) who received tracheostomy. METHODS Demographics and clinical outcomes were obtained through retrospective chart review of 98 infants with sBPD who were born between 2004 and 2017, received tracheostomy at <1 year of age, and were followed in the Infant Tracheostomy and Home Ventilator clinic up to 4 years of age. RESULTS The number of infants with sBPD who received tracheostomy increased significantly over the study period. The median age at tracheostomy was 4 months (IQR 3, 5) or 43 weeks corrected gestational age; the median age at NICU discharge was 7 months (IQR 6, 9). At 48 months of age, all subjects had been liberated from the ventilator, at a median age of 24 months (IQR 18, 29); 52% had been decannulated with a median age at decannulation of 32 months (IQR 26, 39). Only 1 (1%) infant died. Multivariate logistic regression showed infants who were White, liberated from the ventilator by 24 months of age and have public insurance had significantly greater odds of being decannulated by 48 months of age. Tracheobronchomalacia was associated with decreased odds of decannulation. CONCLUSION Infants with sBPD who received tracheostomy had an excellent survival rate. Liberation from home ventilation and decannulation are likely to occur by 4 years of age.
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Affiliation(s)
- Gangaram Akangire
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Charisse Lachica
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Janelle Noel-MacDonnell
- Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA.,Department of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Addie Begley
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Venkatesh Sampath
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - William Truog
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Winston Manimtim
- Division of Neonatology, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, School of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
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Sobotka SA, Lynch E, Msall ME, Graham RJ. Early childhood developmental skills of children with tracheostomies and ventilators recently discharged home. Pediatr Pulmonol 2023; 58:853-865. [PMID: 36448249 PMCID: PMC10680148 DOI: 10.1002/ppul.26265] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/03/2022] [Accepted: 11/25/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Infants who survive prematurity and critical illnesses but require ongoing invasive mechanical ventilation (IMV) are at high risk for developmental disabilities. However, their detailed developmental profiles are largely unknown. OBJECTIVE To understand the developmental profiles of a cohort of young children with IMV after hospital-to-home transition. DESIGN/METHODS Developmental testing was completed 1 month after hospital discharge to determine functioning within motor, cognitive, and communicative domains using (1) the Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS); (2) the Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT); and (3) The Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA-FS). To complement validated testing, semi-structured interviews were conducted with parents to understand perceived influences on neurodevelopment. RESULTS Twenty children were evaluated at median (range) age 11 (5-27) months. Nearly half (45%) were male, 40% non-Hispanic Black, and 25% Hispanic. Sixteen (80%) children were survivors of prematurity. After gestational age correction, median (range) full-scale developmental quotients (DQ) were 69.5 (8-119): CAT DQ 62.5 (3-113) and CLAMS DQ 71.5 (12-125). Parents described that prolonged restriction within the hospital crib away from caregivers, despite hospital therapists, impedes development. Home environments improve development primarily through increased time with parents, but also play outside of the crib. One month after hospital discharge only 10% were receiving early intervention therapies. CONCLUSIONS/SIGNIFICANCE Children with IMV display wide ranges of neurodevelopmental skills with a majority experiencing substantial delays in motor, communicative, and adaptive functioning. The degree and cross-domain challenges highlight the need for targeted and timely therapeutic strategies.
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Affiliation(s)
- Sarah A. Sobotka
- Department of Pediatrics, Section of Developmental and Behavioral Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Emma Lynch
- Department of Pediatrics, Section of Developmental and Behavioral Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Michael E. Msall
- Department of Pediatrics, Section of Developmental and Behavioral Pediatrics, The University of Chicago, Chicago, Illinois, USA
| | - Robert J. Graham
- Department of Anesthesiology, Critical Care and Pain Medicine, Division of Critical Care Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
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Chen LP, Gerber DM, Coller RJ. Admitting what is needed: How the health system and society can reduce hospitalizations for children with medical complexity. J Hosp Med 2023; 18:90-94. [PMID: 35996947 PMCID: PMC9817383 DOI: 10.1002/jhm.12948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Laura P. Chen
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Danielle M. Gerber
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
| | - Ryan J. Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health
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24
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Rush M, Khan A, Barber J, Bloom M, Anspacher M, Fratantoni K, Parikh K. Length of Stay and Barriers to Discharge for Technology-Dependent Children During the COVID-19 Pandemic. Hosp Pediatr 2023; 13:80-87. [PMID: 36519266 PMCID: PMC9808615 DOI: 10.1542/hpeds.2021-006506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVE During the coronavirus disease 2019 pandemic, technology-dependent children are at risk of encountering barriers to hospital discharge because of limits to in-home services. Transition difficulties could increase length of stay (LOS). With this study, we aim to (1) evaluate change in LOS and (2) describe barriers to hospital discharge between prepandemic and early pandemic periods for technology-dependent children. METHODS A retrospective chart review of technology-dependent children discharged from an acute and specialty pediatric hospital within a single urban area between January 1 and May 28, 2020 was conducted. Technology dependence was defined by using a validated complex chronic condition coding system. Patients discharged prepandemic and during the pandemic were compared. Outcomes included LOS and the number and type of discharge barriers (a factor not related to a medical condition that delays discharge). Multivariate regression modeling and parametric and nonparametric analysis were used to compare cohorts. RESULTS Prepandemic, 163 patients were discharged, and 119 were discharged during the early stages of the pandemic. The most common technology dependence was a feeding tube. The unadjusted median LOS was 7 days in both groups. After adjusting for patient-level factors, discharge during the pandemic resulted in a 32.2% longer LOS (confidence interval 2.1%-71.2%). The number of discharge barriers was high but unchanged between cohorts. Lack of a trained caregiver was more frequent during the pandemic (P = .03). CONCLUSIONS Barriers to discharge were frequent for both cohorts. Discharge during the pandemic was associated with longer LOS. It was more difficult to identify a trained caregiver during the pandemic.
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Affiliation(s)
- Margaret Rush
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
| | - Amina Khan
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
| | - John Barber
- Children’s National Hospital, Washington, District of Columbia
| | - Miriam Bloom
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
| | - Melanie Anspacher
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
| | - Karen Fratantoni
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
| | - Kavita Parikh
- Children’s National Hospital, Washington, District of Columbia
- George Washington University, Washington, District of Columbia
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Noritz G, Davidson L, Steingass K. Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy. Pediatrics 2022; 150:e2022060055. [PMID: 36404756 DOI: 10.1542/peds.2022-060055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.
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Affiliation(s)
- Garey Noritz
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; and
| | - Lynn Davidson
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Katherine Steingass
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; and
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Foster C, Kaat AJ, Shaunfield S, Lin E, Coleman C, Storey M, Morales L, Davis MM. PediHome: Development of a Family-Reported Measure of Pediatric Home Healthcare Quality. Acad Pediatr 2022; 22:1510-1519. [PMID: 35439604 DOI: 10.1016/j.acap.2022.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 03/11/2022] [Accepted: 04/08/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE No validated tools exist to measure pediatric home healthcare quality. The objective of this work was to develop a family-reported survey (PediHome) to measure the quality of home healthcare for children with medical complexity (CMC). METHODS A national multidisciplinary expert panel (N = 19) was convened to develop survey content domains. Panelist were joined by 3 additional experts to rank candidate survey items for importance and evaluate relevance and structure. Cognitive interviews were conducted with English-speaking (n = 12) and Spanish-speaking (n = 4) family caregivers of CMC to revise problematic items and clarify response options. A cross-sectional survey was then fielded (6/1/20-10/31/20) to parents whose children receive healthcare at 2 regional academic medical centers. RESULTS The final measure included N = 28 total items with 4 items quantifying access, 1 evaluating overall quality rating, and 21 items assessing provider tasks (11 home nursing only, 2 certified nursing assistant/home health aide only, and 1 dual). Out of 312 caregivers of CMC, 142 (46%) responded and one-half (n = 68, 48%) reported a child receiving home nursing. They received a weekly median of 58.4% (IQR ±31.2%) of approved nursing hours with 55% reporting a missed nursing shift within the last month. Median overall quality was 75-9 (0-10 scale) and median scores on specific quality items ranged from 31-4 to 43-4 (0-4 scale). CONCLUSIONS PediHome is a new content-valid family-reported measure of home healthcare quality for CMC that is useful for evaluating healthcare quality across several domains. Future work will involve assessing PediHome's construct and predictive validity.
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Affiliation(s)
- Carolyn Foster
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics (C Foster and MM Davis), Northwestern University Feinberg School of Medicine, Chicago, Ill; Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center (C Foster and MM Davis), Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill.
| | - Aaron J Kaat
- Department of Medical Social Sciences (AJ Kaat, S Shaunfield, L Morales and MM Davis), Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Sara Shaunfield
- Department of Medical Social Sciences (AJ Kaat, S Shaunfield, L Morales and MM Davis), Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Elaine Lin
- Division of General Pediatrics, Department of Pediatrics (E Lin), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Cara Coleman
- Family Voices National (C Coleman), Lexington, Mass
| | - Margaret Storey
- Ann & Robert H. Lurie Children's Hospital of Chicago Family Advisory Board (M Storey), Chicago, Ill
| | - Luis Morales
- Department of Medical Social Sciences (AJ Kaat, S Shaunfield, L Morales and MM Davis), Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Matthew M Davis
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics (C Foster and MM Davis), Northwestern University Feinberg School of Medicine, Chicago, Ill; Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation Center (C Foster and MM Davis), Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill; Department of Medical Social Sciences (AJ Kaat, S Shaunfield, L Morales and MM Davis), Northwestern University Feinberg School of Medicine, Chicago, Ill; Departments of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine (MM Davis), Chicago, Ill
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High MS, Julion W, Heigel S, Fawcett A, Sobotka SA. Parent education programs for children assisted by invasive mechanical ventilation: A scoping review. J Pediatr Nurs 2022; 66:160-170. [PMID: 35797806 PMCID: PMC10767751 DOI: 10.1016/j.pedn.2022.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/22/2022] [Accepted: 06/17/2022] [Indexed: 11/23/2022]
Abstract
PROBLEM The population of children assisted by invasive mechanical ventilation (IMV) and living at home is growing. Although parent education is essential for safe transitions from hospital-to-home, little is known about how this education is delivered. The aim of this review is to identify existing literature about parent education programs, synthesize the evidence, and identify gaps in the literature for future inquiry. ELIGIBILITY CRITERIA This scoping review was conducted in accordance with the Joanna Briggs Institute methodology. Full-text publications in the English language focused on describing parent education programs for children assisted by IMV, indexed in CINAHL, PubMed, OVID, and PsycINFO and published from 2010 to 2021 were included. Reference lists of relevant articles were reviewed, and a hand search was completed to locate any additional literature outside the original search. SAMPLE A total of 2472 citations were identified. After screening titles and abstracts, 37 full-text articles were retrieved and assessed for eligibility. Two independent reviewers completed the screening process. A hand search located one additional article. A final sample of 18 articles were included in the review. RESULTS The parent education programs described in the final sample included standardized discharge education programs, simulation training, resourcefulness training, patient-specific action plans, disaster preparedness, and symptom and technology management. CONCLUSION Although most parent education programs identified in this review focused on teaching caregiver skills, program characteristics and outcome measures varied widely. IMPLICATIONS This review recommends directions for future research to optimize parent education for children assisted by IMV.
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Affiliation(s)
- Michelle S High
- College of Nursing, Rush University, Chicago, IL, USA; Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Lurie Children's Pediatric Research & Evidence Synthesis Center (PRECIISE): A JBI Affiliated Group, Chicago, IL, USA.
| | | | - Sarah Heigel
- Department of Nursing, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Andrea Fawcett
- Lurie Children's Pediatric Research & Evidence Synthesis Center (PRECIISE): A JBI Affiliated Group, Chicago, IL, USA; Department of Clinical and Organizational Development, Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, Department of Pediatrics, University of Chicago, Chicago, IL, USA
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Barriers to Discharge After Hip Reconstruction Surgery in Non-ambulatory Children With Neurological Complex Chronic Conditions. J Pediatr Orthop 2022; 42:e882-e888. [PMID: 35878419 DOI: 10.1097/bpo.0000000000002219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hip reconstruction surgery in patients with neurological complex chronic conditions (CCC) is associated with prolonged hospitalization and extensive resource utilization. This population is vulnerable to cognitive, developmental, and medical comorbidities which can increase length of stay (LOS). The aims of this study were to characterize barriers to discharge for a cohort of children with neurological CCC undergoing hip reconstruction surgery and to identify patient risk factors for prolonged hospitalization and delayed discharge. METHODS Retrospective chart review of nonambulatory patients with neurological CCC undergoing hip reconstruction surgery between 2007-2016 was conducted. Hospitalization ≥1 day past medical clearance was characterized as delayed discharge. Barriers were defined as unresolved issues at the time of medical clearance and categorized as pertaining to the caregiver and patient education, durable medical equipment, postdischarge transportation/placement, and patient care needs. RESULTS The cohort of 116 patients was 53% male, 16% non-English speaking, and 49% Gross Motor Function Classification System (GMFCS) V with the mean age at surgery of 9.1±3.64 years. Median time from admission to medical clearance was 5 days with median LOS of 6 days. Approximately three-quarters of patients experienced delayed discharge (73%) with barriers identified for 74% of delays. Most prevalent barriers involved education (30%) and durable medical equipment (29%). Postdischarge transportation and placement accounted for 26% of barriers and 3.5 times longer delays ( P <0.001). Factors associated with delayed discharge included increased medical comorbidities ( P <0.05) and GMFCS V ( P <0.001). Longer LOS and medical clearance times were found for female ( P =0.005), older age ( P <0.001), bilateral surgery ( P =0.009), GMFCS V ( P =0.003), and non-English-speaking patients ( P <0.001). CONCLUSIONS Patients with neurological CCC frequently encounter postoperative barriers contributing to increased LOS and delayed discharge. Patients that may be at higher risk for prolonged hospitalization and greater resource utilization include those who are female sex, adolescent, GMFCS V, non-English speaking, have additional comorbidities, and are undergoing bilateral surgery. Standardized preoperative assessment of educational needs, perioperative equipment requirements, and posthospital transportation may decrease the LOS, reduce caregiver and patient burden/distress, cost, and ultimately reduce variation in care delivery. LEVEL OF EVIDENCE Level III, Retrospective Case Series.
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Bird M, Carter N, Lim A, Kazmie N, Fajardo C, Reaume S, McGillion MH. A Novel Hospital-to-Home System for Children With Medical Complexities: Usability Testing Study. JMIR Form Res 2022; 6:e34572. [PMID: 35969456 PMCID: PMC9419046 DOI: 10.2196/34572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Children with medical complexity (CMC) are a group of young people who have severe complex chronic conditions, substantial family-identified service needs, functional limitations, and high health care resource use. Technology-enabled hospital-to-home interventions designed to deliver comprehensive care in the home setting are needed to ease CMC family stress, provide proactive and comprehensive care to this fragile population, and avoid hospital admissions, where possible. Objective In this usability testing study, we aimed to assess areas of strength and opportunity within the DigiComp Kids system, a hospital-to-home intervention for CMC and their families and care providers. Methods Hospital-based clinicians, family members of medically complex children, and home-based clinicians participated in DigiComp Kids usability testing. Participants were recorded and tasked to think aloud while completing usability testing tasks. Participants were scored on the metrics of effectiveness, efficiency, and satisfaction, and the total usability score was calculated using the Single Usability Metric. Participants also provided insights into user experiences during the postusability testing interviews. Results A total of 15 participants (5 hospital-based clinicians, 6 family members, and 4 home-based clinicians) participated in DigiComp Kids usability testing. The participants were able to complete all assigned tasks independently. Error-free rates for tasks ranged from 58% to 100%; the average satisfaction rating across groups was ≥80%, as measured by the Single Ease Question. Task times of participants were variable compared with the task times of an expert DigiComp Kids user. Single Usability Metric scores ranged from 80.5% to 89.5%. In qualitative interviews, participants stressed the need to find the right fit between user needs and the effort required to use the system. Interviews also revealed that the value of the DigiComp Kids system was in its ability to create a digital bridge between hospital and home, enabling participants to foster and maintain connections across boundaries. Conclusions Usability testing revealed strong scores across the groups. Insights gained include the importance of tailoring the implementation of the system to match individual user needs, streamlining key system features, and consideration of the meaning attached to system use by participants to allow for insight into system adoption and sustainment.
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Affiliation(s)
- Marissa Bird
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Nancy Carter
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Audrey Lim
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Nadia Kazmie
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | | | - Shannon Reaume
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Michael H McGillion
- School of Nursing, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
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Home-Based Care for Children with Serious Illness: Ecological Framework and Research Implications. CHILDREN 2022; 9:children9081115. [PMID: 35892618 PMCID: PMC9330186 DOI: 10.3390/children9081115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/15/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022]
Abstract
Care for U.S. children living with serious illness and their families at home is a complex and patchwork system. Improving home-based care for children and families requires a comprehensive, multilevel approach that accounts for and examines relationships across home environments, communities, and social contexts in which children and families live and receive care. We propose a multilevel conceptual framework, guided by Bronfenbrenner’s ecological model, that conceptualizes the complex system of home-based care into five levels. Levels 1 and 2 contain patient and family characteristics. Level 3 contains factors that influence family health, well-being, and experience with care in the home. Level 4 includes the community, including community groups, schools, and providers. Level 5 includes the broader regional system of care that impacts the care of children and families across communities. Finally, care coordination and care disparities transcend levels, impacting care at each level. A multilevel ecological framework of home-based care for children with serious illness and families can be used in future multilevel research to describe and test hypotheses about aspects of this system of care, as well as to inform interventions across levels to improve patient and family outcomes.
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Hofmann M, Yonkaitis C. Lessons Learned from Caregivers of Children with Medical Complexity: Implications for Policy & Providers. Home Healthc Now 2022; 40:196-201. [PMID: 35777940 DOI: 10.1097/nhh.0000000000001083] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
As the number of children with medical complexity living at home continues to grow, so do their care needs. Feedback from parent/guardian caregivers of children with medical complexity provides insight that can help policy makers and healthcare providers to understand more about the care provided in the home. Focus groups, a qualitative study approach, were used to more fully understand the challenges faced by parents/guardian caregivers of children with medical complexity residing in Illinois. Focus groups were conducted in the spring of 2021 to examine the issues from the parent/guardian caregiver perspective. Three main themes emerged from the focus group discussions: navigation of the system is confusing; quality of care in the home needs improvement; and caregivers need more help in providing care. Review of the discussions provided an understanding of the experiences of parent/guardian caregivers of children with medical complexity. These findings have important implications for policy makers, public health and Title V Programs, home nursing agencies, and home nurses. It is imperative that systems level upstream solutions be implemented to address the systemic challenges related to care for the child with medical complexity at home.
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Hamilton H, West AN, Ammar N, Chinthala L, Gunturkun F, Jones T, Shaban-Nejad A, Shah SH. Analyzing Relationships Between Economic and Neighborhood-Related Social Determinants of Health and Intensive Care Unit Length of Stay for Critically Ill Children With Medical Complexity Presenting With Severe Sepsis. Front Public Health 2022; 10:789999. [PMID: 35570956 PMCID: PMC9099028 DOI: 10.3389/fpubh.2022.789999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 03/09/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives Of the Social Determinants of Health (SDoH), we evaluated socioeconomic and neighborhood-related factors which may affect children with medical complexity (CMC) admitted to a Pediatric Intensive Care Unit (PICU) in Shelby County, Tennessee with severe sepsis and their association with PICU length of stay (LOS). We hypothesized that census tract-level socioeconomic and neighborhood factors were associated with prolonged PICU LOS in CMC admitted with severe sepsis in the underserved community. Methods This single-center retrospective observational study included CMC living in Shelby County, Tennessee admitted to the ICU with severe sepsis over an 18-month period. Severe sepsis CMC patients were identified using an existing algorithm incorporated into the electronic medical record at a freestanding children's hospital. SDoH information was collected and analyzed using patient records and publicly available census-tract level data, with ICU length of stay as the primary outcome. Results 83 encounters representing 73 patients were included in the analysis. The median PICU LOS was 9.04 days (IQR 3.99–20.35). The population was 53% male with a median age of 4.1 years (IQR 1.96–12.02). There were 57 Black/African American patients (68.7%) and 85.5% had public insurance. Based on census tract-level data, about half (49.4%) of the CMC severe sepsis population lived in census tracts classified as suffering from high social vulnerability. There were no statistically significant relationships between any socioeconomic and neighborhood level factors and PICU LOS. Conclusion Pediatric CMC severe sepsis patients admitted to the PICU do not have prolonged lengths of ICU stay related to socioeconomic and neighborhood-level SDoH at our center. A larger sample with the use of individual-level screening would need to be evaluated for associations between social determinants of health and PICU outcomes of these patients.
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Affiliation(s)
- Hunter Hamilton
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center College of Medicine, Memphis, TN, United States
| | - Alina N West
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center College of Medicine, Memphis, TN, United States
| | - Nariman Ammar
- University of Tennessee Health Science Center - Oak-Ridge National Laboratory Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, United States
| | - Lokesh Chinthala
- Clinical Trials Network of Tennessee, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Fatma Gunturkun
- University of Tennessee Health Science Center - Oak-Ridge National Laboratory Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, United States
| | - Tamekia Jones
- Departments of Pediatrics and Preventive Medicine, University of Tennessee Health Science Center College of Medicine, Memphis, TN, United States.,Children's Foundation Research Institute Biostatistics Core, Memphis, TN, United States
| | - Arash Shaban-Nejad
- University of Tennessee Health Science Center - Oak-Ridge National Laboratory Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, United States
| | - Samir H Shah
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center College of Medicine, Memphis, TN, United States
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Adams SC, Gura KM, Seres DS, Kovacevich D, Maguire A, Herlitz J, Canada TW, Nishikawa R, Boullata J. Safe care transitions for patients receiving parenteral nutrition. Nutr Clin Pract 2022; 37:493-508. [PMID: 35587169 DOI: 10.1002/ncp.10861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 04/01/2022] [Accepted: 04/02/2022] [Indexed: 01/14/2023] Open
Abstract
Transitions of care require coordination between inpatient healthcare providers, care managers, outpatient/ambulatory providers, and the patient/caregiver and family members. Poor communication during transitions of care can affect health outcomes and economic costs for patients/caregivers, healthcare providers, and healthcare systems. The goal of this paper is to identify risk-prone processes in the transition of care for patients requiring parenteral nutrition (PN) between healthcare environments, including the hospital, home, skilled nursing facility, and long-term acute care hospital settings. To facilitate the evaluation of the transition, a sequential series of steps in the transition process were identified: initial notification, assessment in preparation for transfer, identifying the receiving organization, identifying accountable providers at each sending/receiving organization, communicating the nutrition care plan, implementing the plan and additional considerations regarding PN preparation and readmissions. Safety concerns with risk-prone processes are identified and recommended best practices are proposed for improving processes at each step of the transition. Pediatric considerations are included in the evaluation of the various steps in the transition of care. This paper was approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.
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Affiliation(s)
- Stephen C Adams
- Geisinger Home Infusion Services, Danville, Pennyslvania, USA
| | - Kathleen M Gura
- Boston Children's Hospital Boston, Boston, Massachusetts, USA
| | - David S Seres
- Institute of Human Nutrition, Columbia University Irving Medical Center, New York, New York, USA
| | - Debbie Kovacevich
- Home Care Services Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Jean Herlitz
- University of Chicago Medical Center, Chicago, Iillinois, USA
| | - Todd W Canada
- MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | | | - Joseph Boullata
- JBoullata, PharmD Consulting Services, Philadelphia, Pennsylvania, USA
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Fritz CQ, Hall M, Bettenhausen JL, Beck AF, Krager MK, Freundlich KL, Ibrahim D, Thomson JE, Gay JC, Carroll AR, Neeley M, Frost PA, Herndon AC, Kehring AL, Williams DJ. Child Opportunity Index 2.0 and acute care utilization among children with medical complexity. J Hosp Med 2022; 17:243-251. [PMID: 35535923 PMCID: PMC9254633 DOI: 10.1002/jhm.12810] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Disproportionately high acute care utilization among children with medical complexity (CMC) is influenced by patient-level social complexity. OBJECTIVE The objective of this study was to determine associations between ZIP code-level opportunity and acute care utilization among CMC. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, multicenter study used the Pediatric Health Information Systems database, identifying encounters between 2016-2019. CMC aged 28 days to <16 years with an initial emergency department (ED) encounter or inpatient/observation admission in 2016 were included in primary analyses. MAIN OUTCOME AND MEASURES We assessed associations between the nationally-normed, multi-dimensional, ZIP code-level Child Opportunity Index 2.0 (COI) (high COI = greater opportunity), and total utilization days (hospital bed-days + ED discharge encounters). Analyses were conducted using negative binomial generalized estimating equations, adjusting for age and distance from hospital and clustered by hospital. Secondary outcomes included intensive care unit (ICU) days and cost of care. RESULTS A total of 23,197 CMC were included in primary analyses. In unadjusted analyses, utilization days decreased in a stepwise fashion from 47.1 (95% confidence interval: 45.5, 48.7) days in the lowest COI quintile to 38.6 (36.9, 40.4) days in the highest quintile (p < .001). The same trend was present across all outcome measures, though was not significant for ICU days. In adjusted analyses, patients from the lowest COI quintile utilized care at 1.22-times the rate of those from the highest COI quintile (1.17, 1.27). CONCLUSIONS CMC from low opportunity ZIP codes utilize more acute care. They may benefit from hospital and community-based interventions aimed at equitably improving child health outcomes.
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Affiliation(s)
- Cristin Q. Fritz
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matt Hall
- Children’s Hospital Association, Lenexa, KS
| | - Jessica L Bettenhausen
- Department of Pediatrics, Children’s Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Andrew F Beck
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Molly K Krager
- Department of Pediatrics, Children’s Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Katherine L Freundlich
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dena Ibrahim
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joanna E Thomson
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James C Gay
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison R Carroll
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Maya Neeley
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Patricia A Frost
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison C Herndon
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Allysa L Kehring
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Derek J Williams
- Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
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Boss RD, Henderson CM, Weiss EM, Falck A, Madrigal V, Shapiro MC, Williams EP, Donohue PK. The Changing Landscape in Pediatric Hospitals: A Multicenter Study of How Pediatric Chronic Critical Illness Impacts NICU Throughput. Am J Perinatol 2022; 39:646-651. [PMID: 33075841 DOI: 10.1055/s-0040-1718572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Pediatric inpatient bed availability is increasingly constrained by the prolonged hospitalizations of children with medical complexity. The sickest of these patients are chronic critically ill and often have protracted intensive care unit (ICU) stays. Numbers and characteristics of infants with chronic critical illness are unclear, which undermines resource planning in ICU's and general pediatric wards. The goal of this study was to describe infants with chronic critical illness at six academic institutions in the United States. STUDY DESIGN Infants admitted to six academic medical centers were screened for chronic, critical illness based on a combination of prolonged and repeated hospitalizations, use of medical technology, and chronic multiorgan involvement. Data regarding patient and hospitalization characteristics were collected. RESULTS Just over one-third (34.8%) of pediatric inpatients across the six centers who met eligibility criteria for chronic critical illness were <12 months of age. Almost all these infants received medical technology (97.8%) and had multiorgan involvement (94.8%). Eighty-six percent (115/134) had spent time in an ICU during the current hospitalization; 31% were currently in a neonatal ICU, 34% in a pediatric ICU, and 17% in a cardiac ICU. Among infants who had been previously discharged home (n = 55), most had been discharged with medical technology (78.2%) and nearly all were still using that technology during the current readmission. Additional technologies were commonly added during the current hospitalization. CONCLUSION Advanced strategies are needed to plan for hospital resource allocation for infants with chronic critical illness. These infants' prolonged hospitalizations begin in the neonatal ICU but often transition to other ICUs and general inpatient wards. They are commonly discharged with medical technology which is rarely weaned but often escalated during subsequent hospitalizations. Identification and tracking of these infants, beginning in the neonatal ICU, will help hospitals anticipate and strategize for inpatient bed management. KEY POINTS · 35% of inpatients with chronic critical illness are infants.. · Nearly 90% of these infants spend some time in an intensive care unit.. · 78% are discharged with medical technology..
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Affiliation(s)
- Renee D Boss
- Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Berman Institute of Bioethics, Baltimore, Maryland
| | - Carrie M Henderson
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
- Center for Bioethics and Medical Humanities, Jackson, Mississippi
| | - Elliott M Weiss
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington
| | - Alison Falck
- Division of Neonatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vanessa Madrigal
- Department of Pediatrics, Children's National Medical Center, Washington, Dist. of Columbia
| | - Miriam C Shapiro
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | | | - Pamela K Donohue
- Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Population and Families, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Foster CC, Shaunfield S, Black LE, Labellarte PZ, Davis MM. Improving Support for Care at Home: Parental Needs and Preferences When Caring for Children with Medical Complexity. J Pediatr Health Care 2022; 36:154-164. [PMID: 34688541 DOI: 10.1016/j.pedhc.2020.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/12/2020] [Accepted: 08/20/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We sought to characterize the current supports used by parents to care for children with medical complexity (CMC) at home and parental preferences for additional supports to meet identified gaps. METHOD Semistructured interviews were conducted with parents of 18 CMC. Interviews were transcribed then analyzed using a constant comparative approach. RESULTS Extended family and community offloaded nonmedical tasks, assisted financially, gave emotional reinforcement, and cared for CMC. Home health providers also directly cared for CMC, but access and quality varied. Government programs paid for in-home care, but eligibility varied. Parents wanted more paid home care but also more support completing nonmedical tasks, mitigating financial strains, and accessing mental health services. DISCUSSION Parents of CMC relied on family and community members to help fill existing gaps in-home care, but gaps remained, suggesting the need for more medical and social supports for the in-home care of CMC and their families.
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Sobotka SA, Hall DE, Thurm C, Gay J, Berry JG. Home Health Care Utilization in Children With Medicaid. Pediatrics 2022; 149:184489. [PMID: 35028664 PMCID: PMC9003864 DOI: 10.1542/peds.2021-050534] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Although many children with medical complexity (CMC) use home health care (HHC), little is known about all pediatric HHC utilizers. Our objective was to assess characteristics of pediatric HHC recipients, providers, and payments. METHODS We conducted a retrospective analysis of 5 209 525 children age 0-to-17 years enrolled Medicaid in the 2016 IBM Watson MarketScan Medicaid Database. HHC utilizers had ≥ 1 HHC claim. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes were reviewed to codify provider types when possible: registered nurse (RN), licensed practical nurse (LPN), home health aide (HHA), certified nursing assistant (CNA), or companion/personal attendant. Enrollee clinical characteristics, HHC provider type, and payments were assessed. Chronic conditions were evaluated with Agency for Healthcare Research and Quality's Chronic Condition Indicators and Feudtner's Complex Chronic Conditions. RESULTS Of the 0.8% of children who used HHC, 43.8% were age <1 year, 25% had no chronic condition, 38.6% had a noncomplex chronic condition, 21.5% had a complex chronic condition without technology assistance, and 15.5% had technology assistance (eg, tracheostomy). HHC for children with technology assistance accounted for 72.6% of all HHC spending. Forty-five percent of HHC utilizers received RN/LPN-level care, 7.9% companion/personal attendant care, 5.9% HHA/CNA-level care, and 36% received care from an unspecified provider. For children with technology assistance, the majority (77.2%) received RN/LPN care, 17.5% companion/personal assistant care, and 13.8% HHA/CNA care. CONCLUSIONS Children using HHC are a heterogeneous population who receive it from a variety of providers. Future investigations should explore the role of nonnurse caregivers, particularly with CMC.
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Affiliation(s)
- Sarah A. Sobotka
- Department of Pediatrics, Section of Developmental and Behavioral Pediatrics, University of Chicago, Chicago, Illinois
| | - David E. Hall
- Monroe Carell Jr, Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cary Thurm
- Children’s Hospital Association, Lenexa, Kansas
| | - James Gay
- Monroe Carell Jr, Children’s Hospital at Vanderbilt, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jay G. Berry
- Department of Pediatrics, Division of General Pediatrics, Complex Care Service, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Joshi R, Marvin W. Apnea with ketamine sedation in a patient with severe anorexia nervosa: A case report. Eat Weight Disord 2022; 27:387-389. [PMID: 33788180 DOI: 10.1007/s40519-021-01176-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/17/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND There is a paucity of literature around sedation and anesthesia in patients with severe anorexia nervosa. Chronically malnourished patients are known to have myopathy, neuropathy, and altered neurotransmitter signaling. Ketamine is a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist that is an established general anesthetic and short-acting dissociative analgesic agent. It generally has a reassuring adverse event profile and rarely has been reported to result in apnea. We aim to raise awareness of this untoward adverse event in patients with severe anorexia nervosa among sedation providers and those referring patients for hospitalization or sedation. CASE PRESENTATION We describe an episode of apnea, a rare adverse event of ketamine, which was given for procedural sedation to a severely malnourished 13-year-old female with anorexia nervosa, generalized anxiety disorder, and high-functioning autism spectrum disorder. She had no history of apnea nor of ketamine sedation. She was given a standard dose of ketamine and had no other central nervous system depressants within 24 h. Within 1 min after slow medication administration, she had a 9-min period of apnea without laryngospasm. She was supported with bag-valve-mask ventilation throughout this period and did not require intubation. She returned to baseline shortly after procedural sedation. CONCLUSIONS This case describes apnea after ketamine sedation in a patient with severe anorexia nervosa. It supports the importance of a thorough pre-procedure review of a patient's underlying medical problems and the consideration of how sedatives may interact with these conditions. We aim to alert those who care for this complex population of the possible altered neurotransmitters, myopathy, and adverse response to sedation, anesthetics, and analgesics.
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Affiliation(s)
- Reshma Joshi
- PGY-3, Department of Pediatrics and Pediatric Neurology, Medical University of South Carolina, SJCH, 10 McClennan Banks Dr. MSC 915, Charleston, SC, 29425, USA
| | - Whitney Marvin
- Pediatric Critical Care, Medical University of South Carolina, 125 Doughty Street MSC 917, Charleston, SC, 29425, USA.
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Mayara Vieira de Macena P, Fernandes LTB, Matias Santos M, Collet N, de Oliveira Toso BRG, Vaz EMC. Professional Care in Home for Children and Teenagers with Special Health Needs: An Integrative Review. AQUICHAN 2022. [DOI: 10.5294/aqui.2022.22.1.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective: Analyzing the results of scientific publications on professional home care for children and teenagers with special health needs.
Materials and method: An integrative review with articles published between 2009 and 2020 conducted in the BDEnf, Lilacs, Medline/PubMed databases and in the SciELO electronic library. The data were analyzed in four stages: data reduction; display of the data; comparison of data; drawing and verification of completion.
Results: There were identified 5,641 articles; after the application of the inclusion and exclusion criteria and disposal of duplicates, 637 articles were chosen for the reading of titles and abstracts, of which 61 were selected for full reading and of these, 28 composed the final sample. The offer of remote support actions and concern in training caregivers regarding the technical-scientific aspects of home care was identified, in addition to promoting the improvement of the quality of life of children/teenagers and their families. A gap was evidenced regarding the identification and management of pain by home service professionals.
Conclusions: The performance of home services to this specific population focuses on the demands of care with health technologies and on promoting symptom relief, reducing the workload of caregivers and assisting in dehospitalization.
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Berry JG, Casto E, Dumas H, O'Brien J, Steinhorn D, Marks M, Traul C, Wilson K, Simpser E. National survey of health services provided by pediatric post-acute care facilities in the US. J Pediatr Rehabil Med 2022; 15:417-424. [PMID: 35754294 DOI: 10.3233/prm-201519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE The need for pediatric post-acute facility care (PAC) is growing due to technological advances that extend the lives of many children, especially those with complex medical needs. The objectives were to describe [1] the types and settings of PAC; [2] the clinical characteristics of the pediatric patients requiring PAC; and [3] perceptions of PAC care delivery by clinical staff. METHODS An online survey was administered between 6/2018 to 12/2018 to administrative leaders in PAC facilities that have licensed beds for children and who were active members of the Pediatric Complex Care Association. Survey topics included types of health services provided; pediatric patient characteristics; clinical personnel characteristics; and perceptions of pediatric PAC health care delivery. RESULTS Leaders from 26 (54%) PAC facilities in 16 U.S. states completed the survey. Fifty-four percent identified as skilled nursing facility/long-term care, 19% intermediate care facilities, 15% respite and medical group homes, and 12% post-acute rehabilitation facilities. Sixty-nine percent of facilities had a significant increase in the medical complexity of patients over the past 10 years. Most reported capability to care for children with tracheostomy/invasive ventilation (100%), gastrostomy tubes (96%), intrathecal baclofen pump (89%), non-invasive positive pressure ventilation (85%), and other medical technology. Most facilities (72%) turned away patients for admission due to bed unavailability occasionally or always. Most facilities (62%) reported that insurance reimbursement to cover the cost of providing PAC to children was not acceptable, and most reported that it was difficult to hire clinical staff (77%) and retain staff (58%). CONCLUSION PAC in the U.S. is provided to an increasingly medically-complex population of children. There is a critical need to investigate financially-viable solutions for PAC facilities to meet the patient demands for their services and to sufficiently reimburse and retain staff for the challenging and important care that they provide.
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Affiliation(s)
- Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Casto
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | | | | | | | - Michelle Marks
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA.,Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland, OH, USA
| | - Christine Traul
- Cleveland Clinic Children's Hospital for Rehabilitation, Cleveland, OH, USA
| | - Karen Wilson
- Division of General Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Paitich L, Luedemann C, Giel J, Maynard R. Allocation of Pediatric Home Care Nursing Hours: The Minnesota Experience. Home Healthc Now 2022; 40:27-39. [PMID: 34994718 PMCID: PMC8740033 DOI: 10.1097/nhh.0000000000001035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Despite an increasing demand for pediatric home care nursing, there is no comprehensive or universal standard of care for prescribing pediatric home care nursing hours based on a child's medical complexity. Adoption of a qualification tool (QT) to allocate home care nursing hours based on the medical complexity of a child may mitigate inequality in access to care and improve the patient and family experience. A QT, developed in Minnesota, recommends home care nursing hours based on the level of medical complexity and need for skilled nursing interventions. Four hypothetical case studies demonstrate the use of the QT to calculate recommended nursing hours. To validate the tool, a survey of discharge planners found a percentage difference in calculated hours of 4.1, 5.7, 11.2, and 24.9 in the four case studies. Discharge planners rated the usability of the QT as favorable with a score of 3.6 on a Likert scale of 5. The recommended nursing hours prescribed for families, based on the QT, was perceived as meeting the needs of the child by 56% and 42% of surveyed parents and home care nurses (HCNs), respectively. The need for additional nursing hours was expressed by 33% and 50% of parents and nurses, respectively. In general, HCNs' assessment of allocated nursing hours paralleled that of parents. Further refinement and adoption of a standardized QT to allocate home care nursing hours may improve access and outcomes for children requiring home care nursing.
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Bayer ND, Hall M, Li Y, Feinstein JA, Thomson J, Berry JG. Trends in Health Care Use and Spending for Young Children With Neurologic Impairment. Pediatrics 2022; 149:183773. [PMID: 34854922 PMCID: PMC8762668 DOI: 10.1542/peds.2021-050905] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Children with neurologic impairment (NI) are a growing subset of children who frequently use health care. We examined health care use and spending trends across services for children with NI during their first 5 years of life. METHODS This was a retrospective study of 13 947 children with NI in the multistate IBM Medicaid MarketScan Database (2009-2017). We established birth cohorts of children with NI and analyzed claims from birth to 5 years. NI, identified by using International Classification of Diseases, 9th Revision, diagnosis codes, was defined as ≥1 neurologic diagnosis that was associated with functional and/or intellectual impairment. We measured annual health care use and per-member-per-year spending by inpatient, emergency department (ED), and outpatient services. Population trends in use and spending were assessed with logistic and linear regression, respectively. RESULTS During their first versus fifth year, 66.8% vs 5.8% of children with NI used inpatient services, and 67.8% vs 44.4% used ED services. Annual use in both categories decreased over 0-5 years (inpatient odds ratio: 0.35, 95% confidence interval: 0.34 to 0.36; ED odds ratio: 0.78, 95% confidence interval: 0.77 to 0.79). The use of outpatient services (primary care, specialty care, home health) decreased gradually. Per-member-per-year spending on inpatient services remained the largest spending category: $83 352 (90.2% of annual spending) in the first year and $1944 (25.5%) in the fifth year. CONCLUSIONS For children with early-onset NI from 0-5 years, use and spending on inpatient services decreased dramatically; ED and outpatient service use decreased more gradually. These findings may help systems, clinicians, and families optimize care by anticipating and adjusting for shifting use of health care services.
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Affiliation(s)
- Nathaniel D. Bayer
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Rochester and Golisano Children’s Hospital, Rochester, New York,Address correspondence to Nathaniel D. Bayer, MD, Division of Pediatric Hospital Medicine, Golisano Children’s Hospital and Department of Pediatrics, University of Rochester, 601 Elmwood Ave, Box 667, Rochester, NY 14642. E-mail:
| | | | - Yue Li
- Department of Public Health Sciences, University of Rochester, Rochester, New York
| | - James A. Feinstein
- Adult and Child Consortium for Health Outcomes Research & Delivery Science, University of Colorado and Children’s Hospital Colorado, Aurora, Colorado
| | - Joanna Thomson
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, College of Medicine University of Cincinnati, Cincinnati, Ohio
| | - Jay G. Berry
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
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Singh H, Morrison M, McIltrot K. Education Following Pediatric Gastrostomy Tube Placement: An Integrative Review. J Pediatr Nurs 2021; 61:387-393. [PMID: 34601247 DOI: 10.1016/j.pedn.2021.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 09/10/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is a gap in knowledge regarding the necessary components for pediatric gastrostomy tube education. This integrative review addresses the question "What are the educational components following pediatric gastrostomy placement?" METHODS A literature search was conducted using PubMed, CINAHL, and Cochrane Library electronic databases, along with a hand search. Articles for review included those in the pediatric population, English language, and publication dates between 2010 and 2020. RESULTS Ultimately, 7 articles met the inclusion criteria for review. Articles were all pediatric focused (0-18 years), and were a mix of quantitative and qualitative designs, along with one non-research paper. Three major themes were identified from the literature including that gastrostomy tube education should be a multidisciplinary effort, that education should take a standardized approach, and that it should include psychosocial elements that enhance caregiver knowledge and empowerment. DISCUSSION This review demonstrates that while there is no consensus on a superior mode or means of education, pediatric gastrostomy discharge education must be standardized and high quality to promote the best patient and caregiver outcomes. Further research should aim to address which forms of education, if any, lead to the best outcomes, and how education can best be delivered to promote caregiver knowledge and ease.
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Kalm B, Lai K, Darro N. Care of children with home mechanical ventilation in the healthcare continuum. Hosp Pract (1995) 2021; 49:456-466. [PMID: 34605728 DOI: 10.1080/21548331.2021.1988608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction:The care of children with invasive home mechanical ventilation (HMV) is challenging and insufficiently described in the literature. Objectives:Our objective regarding this unique and growing population is to describe our institution's pediatric chronic HMV program and discuss our current understanding of best care practices. Methods: In addition to characterizing the clinical landscape of our program, we describe demographics for our roughly 223 current HMV patients with comparisons to available national data. We discuss evidence and expert opinion regarding various elements of care including initiation of HMV, caregiver education, equipment concerns, inpatient care, and longitudinal care.Results: Data was collected but not statistically analyzed for our roughly 223 current patients and historical cohort. Descriptive data included demographic information, patient medical characteristics and complexity, and reasons for rehospitalizations.Conclusions:While we have provided institutional expertise regarding the care of this complex population, the evidence base remains insufficient and there are many areas which need future research to develop standardized care practice guidelines for children with HMV.
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Affiliation(s)
- Benjamin Kalm
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Khanh Lai
- Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Natalie Darro
- Division of Pediatric Complex Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Mitchell SM. True Resilience: A Look Inside COVID's Effect on Children with Medical Complexity and Their Families. CURRENT PEDIATRICS REPORTS 2021; 9:171-177. [PMID: 34659915 PMCID: PMC8501934 DOI: 10.1007/s40124-021-00254-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 01/10/2023]
Abstract
Purpose of Review Vulnerable children with medical complexity are silent victims of the COVID-19 pandemic, impacted by lack of resources and sick caregivers. In this article, we examine ways in which the pandemic has increased the significant difficulties already experienced by these patients and their families. Increased awareness will lead to improvement in the disparities experienced by this population and improve the ability of healthcare providers to care for them. Recent Findings The number of children living with medical complexity is rapidly increasing. They face unique circumstances which can lead to compromise in care. This population is especially at risk for complications related to COVID, so may have a more prolonged admission with more morbidities. Children of ethnic minorities are also more impacted by severe illness and death. Finally, access to palliative care has been limited, which is a huge part in caring for these children who have life-long medical care needs. Summary Children with medical complexity have unique circumstances and the entirety of the effect of the coronavirus pandemic on this group is unknown. While the medical world has found ways to adapt, these changes can increase disparities for this population. Given the increase in number of children with medical complexity living in the USA, it is important to continue to consider the unique challenges they face in the current pandemic and improve the care delivery for both the child and his or her family.
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Affiliation(s)
- Sarah M Mitchell
- Department of Pediatrics-Hospitalist Based Medicine, LaRabida Children's Hospital, 6501 S. Promotory Dr., Chicago, IL 60653 USA
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Discharge Practices for Children with Home Mechanical Ventilation across the United States. Key-Informant Perspectives. Ann Am Thorac Soc 2021; 17:1424-1430. [PMID: 32780599 DOI: 10.1513/annalsats.201912-875oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: In 2016, the American Thoracic Society released clinical practice guidelines for pediatric chronic home invasive ventilation pertaining to discharge practices and subsequent management for patients with invasive ventilation using a tracheostomy. It is not known to what extent current U.S. practices adhere to these recommendations.Objectives: Hospital discharge practices and home health services are not standardized for children with invasive home mechanical ventilation (HMV). We assessed discharge practices for U.S. children with HMV.Methods: A survey of key-informant U.S. clinical providers of children with HMV, identified with purposeful and snowball sampling, was conducted. Topics included medical stability, family caregiver training, and discharge guidelines. Close-ended responses were analyzed using descriptive statistics. Responses to open-ended questions were analyzed using open coding with iterative modification for major theme agreement.Results: Eighty-eight responses were received from 157 invitations. Eligible survey responses from 59 providers, representing 44 U.S. states, included 49.2% physicians, 37.3% nurses, 10.2% respiratory therapists, and 3.4% case managers. A minority, 22 (39%) reported that their institution had a standard definition of medical stability; the dominant theme was no ventilator changes 1-2 weeks before discharge. Nearly all respondents' institutions (94%) required that caregivers demonstrate independent care; the majority (78.4%) required two trained HMV caregivers. Three-fourths described codified discharge guidelines, including the use of a discharge checklist, assurance of home care, and caregiver training. Respondents described variable difficulty with obtaining durable medical equipment, either because of insurance or durable-medical-equipment company barriers.Conclusions: This national U.S. survey of providers for HMV highlights heterogeneity in practice realities of discharging pediatric patients with HMV. Although no consensus exists, defining medical stability as no ventilator changes 1-2 weeks before discharge was common, as was having an institutional requirement for training two caregivers. Identification of factors driving heterogeneity, data to inform standards, and barriers to implementation are needed to improve outcomes.
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Shaikh N, Umscheid J, Rizvi S, Bhatt P, Vasudeva R, Yagnik P, Bhatt N, Donda K, Dapaah-Siakwan F. National Trends of Acute Osteomyelitis and Peripherally Inserted Central Catheters in Children. Hosp Pediatr 2021; 11:662-670. [PMID: 34187789 DOI: 10.1542/hpeds.2020-005794] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Although a growing body of evidence suggests that early transition to oral antimicrobial therapy is equally efficacious to prolonged intravenous antibiotics for treatment of acute pediatric osteomyelitis, little is known about the pediatric trends in peripherally inserted central catheter (PICC) placements. Using a national database, we examined incidence rates of pediatric hospitalizations for acute osteomyelitis in the United States from 2007 through 2016, as well as the trends in PICC placement, length of stay (LOS), and cost associated with these hospitalizations. METHODS This was a retrospective, serial cross-sectional study of the National Inpatient Sample database from 2007 through 2016. Patients ≤18 years of age with acute osteomyelitis were identified by using appropriate diagnostic codes. Outcomes measured included PICC placement rate, LOS, and inflation-adjusted hospitalization costs. Weighted analysis was reported, and a hierarchical regression model was used to analyze predictors. RESULTS The annual incidence of acute osteomyelitis increased from 1.0 to 1.8 per 100 000 children from 2007 to 08 to 2015 to 16 (P < .0001), whereas PICC placement rates decreased from 58.8% to 5.9% (P < .0001). Overall, changes in LOS and inflation-adjusted hospital costs were not statistically significant. PICC placements and sepsis were important predictors of increased LOS and hospital costs. CONCLUSIONS Although PICC placement rates for acute osteomyelitis significantly decreased in the face of increased incidence of acute osteomyelitis in children, LOS and hospital costs for all hospitalizations remained stable. However, patients receiving PICC placements had longer LOS. Further studies are needed to explore the long-term outcomes of reduced PICC use.
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Affiliation(s)
- Nadia Shaikh
- Department of Pediatrics, University of Illinois College of Medicine at Peoria, Illinois;
| | - Jacob Umscheid
- School of Medicine, University of Kansas, Wichita, Kansas
| | - Syed Rizvi
- Department of Pediatrics, St. Louis University, St. Louis, Missouri
| | - Parth Bhatt
- United Hospital Center, Bridgeport, West Virginia
| | | | - Priyank Yagnik
- School of Medicine, University of Kansas, Wichita, Kansas
| | - Neel Bhatt
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Keyur Donda
- Department of Pediatrics, University of South Florida, Tampa, Florida; and
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Raisanen JC, Ruth A, Donohue PK, Detwiler K, Fratantoni K, Huff SM, Boss RD. Paying for Pediatric Home Health Care: How Families of Children With Medical Complexity Navigate Gaps in Coverage. FAMILY & COMMUNITY HEALTH 2021; 44:184-193. [PMID: 33927166 DOI: 10.1097/fch.0000000000000300] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Limited private and public financing of home health care for children with medical complexity can have harmful and costly consequences. Little is known of how parents and professionals in the United States navigate coverage for these services or how payer restrictions are shaping service quality. Qualitative interviews were conducted with families and professionals (eg, prescribers, providers, administrators of pediatric home health care [PHHC]) caring for children with medical complexity. Interview transcripts were analyzed using inductive thematic analysis. In total, 47 families and 45 professionals from across 31 states and the District of Columbia had experiences with the full range of PHHC services. Participants detailed the need to patch together multiple insurances and payment programs to cover a child's home health needs. They described nontransparent eligibility determinations that do not reflect the diagnostic uncertainty and static functional status that is common for many children. Coverage denials are common, leaving gaps in care that can potentiate downstream cost escalation. Evidence-based health care reform must ensure that children get the PHHC needed to maintain function and reduce the need for hospital-based services. Recommendations are offered to improve PHHC financing and care for the most medically vulnerable children and their families.
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Affiliation(s)
- Jessica C Raisanen
- Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland (Mss Raisanen and Ruth and Dr Boss); Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ms Ruth and Dr Donohue); Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland (Drs Donohue and Boss); Division of General and Community Pediatrics, Children's National Hospital, Washington, District of Columbia (Ms Detwiler and Dr Fratantoni) and Johns Hopkins Home Health Group, Baltimore, Maryland (Ms Huff). Ms Detwiler is the parent of a child with medical complexity
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Hardy RY, Liu GC, Conkol KJ, Gleeson SP, Kelleher KJ. Left behind again: Rural home health services in a Medicaid pediatric accountable care organization. J Rural Health 2021; 38:420-426. [PMID: 33978993 PMCID: PMC9291131 DOI: 10.1111/jrh.12587] [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] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose To contrast trends in rural and urban pediatric home health care use among Medicaid enrollees. Methods Medicaid administrative claims data were used to assess differences in home health care use for child members in a large pediatric accountable care organization (ACO) in Ohio. Descriptive statistics assessed rural and urban differences in health care use over a 10‐year period between 2010 and 2019. Findings Pediatric home health care use increased markedly in the low‐income (CFC) and disabled (ABD) Medicaid categories. Over the past 10 years, CFC‐enrolled children from urban communities have seen more home health visits, fewer emergency department (ED) visits, and more well child visits compared to rural CFC‐enrolled children. Children enrolled due to disabilities in urban communities have also seen more home health visit use but fewer preventive care visits than their rural counterparts. Conclusions Within a pediatric ACO, rural home health care use has remained relatively stagnant over a 10‐year period, a stark contrast to increases in home health care use among comparable urban populations. There are likely multiple explanations for these differences, including overuse in urban communities, lack of access in rural communities, and changes to home health reimbursement. More can be done to improve rural home health access. Such improvement will likely necessitate large‐scale changes to home health care delivery, workforce, and financing. Improvements should be evaluated for return‐on‐investment not only in terms of direct costs, that is, reduced inpatient or ED costs, but also in terms of patient and family quality‐of‐life or key indicators of child well‐being such as educational attainment.
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Affiliation(s)
- Rose Y Hardy
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Center for Innovation in Pediatric Practice, Columbus, Ohio, USA
| | - Gilbert C Liu
- Partners For Kids, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - Sean P Gleeson
- Partners For Kids, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kelly J Kelleher
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Center for Innovation in Pediatric Practice, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
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Hannan KE, Bourque SL, Palmer C, Tong S, Hwang SS. Prevalence and Predictors of Medical Complexity in a National Sample of VLBW Infants. Hosp Pediatr 2021; 11:525-535. [PMID: 33906959 DOI: 10.1542/hpeds.2020-004945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Very low birth weight (VLBW) infants are at high risk for morbidities beyond the neonatal period and ongoing use of health care. Specific morbidities have been studied; however, a comprehensive landscape of medical complexity in VLBW infants has not been fully described. We sought to (1) describe the prevalence of complex chronic conditions (CCCs) and (2) determine the association of demographic, hospital, and clinical factors with CCCs and CCCs or death. METHODS This retrospective cross-sectional analysis of discharge data from the Kids' Inpatient Database (2009-2012) included infants with a birth weight <1500 g and complete demographics. Outcomes included having CCCs or having either CCCs or dying. Analyses were weighted; univariate and multiple logistic regression models were used to estimate unadjusted and adjusted odds ratios. A dominance analysis with Cox-Snell R 2 determined the relative contribution of demographic, hospital, and clinical factors to the outcomes. RESULTS Among our weighted cohort of >78 000 VLBW infants, >50% had CCCs or died. After adjustments, the prevalence of CCCs or CCCs or death differed by sex, race and ethnicity, hospital location, US region, receipt of surgery, transfer status, and birth weight. Clinical factors accounted for the highest proportion of the model's ability to predict CCCs and CCCs or death at 93.3% and 96.3%, respectively, whereas demographic factors were 11.5% and 2.3% and hospital factors were 5.2% and 1.4%, respectively. CONCLUSIONS In this nationally representative analysis, medical complexity is high among VLBW infants. Varying contributions of demographic, hospital, and clinical factors in predicting medical complexity offer opportunities to investigate future interventions to improve care delivery and patient outcomes.
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Affiliation(s)
- Kathleen E Hannan
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Stephanie Lynn Bourque
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Claire Palmer
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Suhong Tong
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Sunah Susan Hwang
- Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
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