Pediatric invasive device utility and harm: a multi-site point prevalence survey

BACKGROUND AND AIMS

Invasive devices are widely used in healthcare settings; however, pediatric patients are especially vulnerable to invasive device-associated harm. This study aimed to explore invasive device utility, prevalence, harm, and clinical practice across three Australian pediatric tertiary hospitals.

METHODS

In 2022-2023, a multi-center, observational, rolling-point-prevalence survey was conducted. Fifty-per-cent of inpatients were systemically sampled by random allocation. Patients with devices were then followed for up to 3-days for device-related complications/failures and management/removal characteristics.

RESULTS

Of the 285 patients audited, 78.2% had an invasive device (n = 412 devices), with a median of 1 device-per-patient (interquartile range 1-2), with a maximum of 13 devices-per-patient. Over half of devices were vascular access devices (n = 223; 54.1%), followed by gastrointestinal devices (n = 112; 27.2%). The point-prevalence of all device complications on Day 0 was 10.7% (44/412 devices) and period-prevalence throughout the audit period was 27.7% (114/412 devices). The period-prevalence of device failure was 13.4% (55/412 devices).

CONCLUSIONS

The study highlighted a high prevalence of invasive devices among hospitalized patients. One-in-ten devices failed during the audit period. These findings underscore the need for vigilant monitoring and improved strategies to minimize complications and enhance the safety of invasive devices in pediatric hospital settings.

IMPACT

A high prevalence of invasive devices among hospitalized patients was reported. Of the 285 patients audited, almost 80% had an invasive device (total 412 devices), with a median of 1 device-per-patient and a maximum of 13 devices-per-patient. The most common devices used in pediatric healthcare are vascular access devices (n = 223; 54.1%), however, 16% (n = 36) of these devices failed, and one-third had complications. The point prevalence of all device complications at day 0 was 10.7% (44 out of 412 devices), with a period prevalence of 27.7% (114 out of 412 devices) throughout the audit period.

Device Related Thrombosis and Bleeding in Pediatric Health Care: A Meta-analysis

CONTEXT

The risk of invasive device-related thrombosis and bleeding contributes to morbidity and mortality, yet their prevalence by device-types is poorly understood.

OBJECTIVES

This study aimed to estimate pooled proportions and rates of thrombotic and bleeding complications associated with invasive devices in pediatric health care.

DATA SOURCES

Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.

STUDY SELECTION

Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) reporting thrombotic and bleeding complications, and (4) published in English, were included.

DATA EXTRACTION

Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used.

MAIN OUTCOMES AND MEASURES

Device-specific pooled thromboses (symptomatic, asymptomatic, unspecified) and bleeding (major, minor).

RESULTS

Of the 107 studies, 71 (66%) focused on central venous access devices. Symptomatic venous thromboembolism in central venous access devices was 4% (95% confidence interval [CI], 3-5; incidence rate 0.03 per 1000 device-days, 95% CI, 0.00-0.07), whereas asymptomatic was 10% (95% CI, 7-13; incidence rate 0.25 per 1000 device-days, 95% CI, 0.14-0.36). Both ventricular assist devices (28%; 95% CI, 19-39) and extracorporeal membrane oxygenation (67%; 95% CI, 52-81) were often associated with major bleeding complications.

CONCLUSIONS

This comprehensive estimate of the incidence and prevalence of device-related thrombosis and bleeding complications in children can inform clinical decision-making, guide risk assessment, and surveillance.

Goals of the Morbidity and Mortality meeting in acute care: A scoping review

OBJECTIVE

The objective of this study was to describe what is known about understandings of the goals of the Morbidity and Mortality meeting.

REVIEW METHODS USED

The study utilised scoping review methodology.

DATA SOURCES

Papers in English presenting empirical data published in academic journals with Morbidity and Mortality meetings as the central concept of study. Included papers presented data about the perception of stakeholders about goals of the Morbidity and Mortality meeting. Medline, Embase, and CINAHL databases were search conducted from earliest record - October 20th 2021. A manual search of the reference lists of all included papers identified further eligible papers.

REVIEW METHODS

Data about the location, participant type, and methods/ methodology were extracted and entered onto a database. Content analysis of the results and discussion sections of qualitative papers yielded broad categories of meeting goal. This provided a framework for the organisation of the quantitative findings, which were subsequently extracted and charted under these categories.

RESULTS

Twenty-five papers were included in the review, and six main categories were identified in the qualitative synthesis of findings. These included meeting goals related to quality and safety, education, legal and reputational risk management, professional culture, family/caregivers, and peer support.

CONCLUSIONS

There are heterogeneous understandings of key terminologies used to describe Morbidity and Mortality meeting goals, particularly evident within understandings of educational and quality and safety meeting goals. This paper defines and unravels this complexity in a way that researchers and clinicians can define, compare and evaluate their own department's meeting goals.

Guiding warfarin self-management in children: development of a warfarin nomogram

Background

Warfarin therapy in children is impacted by many variables. To support the implementation of a self-management program within a pediatric anticoagulation service, a pediatric-specific warfarin nomogram was needed. A literature review revealed no published pediatric nomograms; therefore, a nomogram was developed drawing upon an evidence-based "Warfarin Information for Clinicians" hospital guideline.

Objectives

This study aimed to evaluate the suitability of a pediatric warfarin nomogram.

Methods

A retrospective audit of electronic medical records compared the dosing and international normalized ratio (INR) retest decisions made by hematology clinicians to the dosing and retesting recommended by a new warfarin nomogram at a pediatric hospital. Children (aged 6 months-18 years) receiving warfarin therapy for >6 months were included. Data were collected between September 2019 and February 2020. Descriptive data analysis was performed. The study was approved by the hospital's Human Research Ethics Committee.

Results

Warfarin dosing and INR retest decisions for 39 children were included, equating to 521 INRs. The nomogram matched 81.4% of clinicians dosing decisions and 30% of INR retest decisions. Moreover, 59% of the clinician-recommended retest dates were earlier than the nomogram recommendation. In the INR 2.0-3.0 group, 84.4% of dosing decisions and 72% of retest decisions matched the nomogram.

Conclusions

These results suggest that this pediatric nomogram is a suitable tool for warfarin dosing, as recommended warfarin doses matched the majority of clinicians' decisions. Modification may be needed to nomogram recommendations for the time to retest. This nomogram can be used to support warfarin self-management and may assist clinicians and patients or families in making evidence-based dosing decisions.

Factors XI and XII in extracorporeal membrane oxygenation: longitudinal profile in children

Background

Extracorporeal membrane oxygenation (ECMO) is used in children with cardiopulmonary failure. While the majority of ECMO centers use unfractionated heparin, other anticoagulants, including factor XI and factor XII inhibitors are emerging, which may prove suitable for ECMO patients. However, before these anticoagulants can be applied in these patients, baseline data of FXI and FXII changes need to be acquired.

Objectives

This study aimed to describe the longitudinal profile of FXI and FXII antigenic levels and function before, during, and after ECMO in children.

Methods

This is a prospective observational study in neonatal and pediatric patients with ECMO (<18 years). All patients with venoarterial ECMO and with sufficient plasma volume collected before ECMO, on day 1 and day 3, and 24 hours postdecannulation were included. Antigenic levels and functional activity of FXI and FXII were determined in these samples. Longitudinal profiles of these values were created using a linear mixed model.

Results

Sixteen patients were included in this study. Mean FXI and FXII antigenic levels (U/mL) changed from 7.9 and 53.2 before ECMO to 6.0 and 34.5 on day 3 and they recovered to 8.8 and 39.4, respectively, after stopping ECMO. Function (%) of FXI and FXII decreased from 59.1 and 59.0 to 49.0 and 50.7 on day 3 and recovered to 66.0 and 54.4, respectively.

Conclusion

This study provides the first insights into changes of the contact pathway in children undergoing ECMO. FXI and FXII antigen and function change during ECMO. Results from this study can be used as starting point for future contact pathway anticoagulant studies in pediatric patients with ECMO.

The management of pain during pediatric hematopoietic stem cell transplantation: A qualitative study of contextual factors that influenced pain management practices

BACKGROUND

Children hospitalized following hematopoietic stem cell transplantation (HSCT) experience complex and prolonged pain in response to the intensity of this treatment.

OBJECTIVES

To describe how pain was managed for children during HSCT therapy and how contextual factors related to the clinical environment influenced healthcare providers' and parents' pain management practices.

METHODS

A qualitative case study was conducted and involved semi-structured interviews at two time points following transplantation (30 and 90 days) with parents (n = 10) and naturalistic observations of pain-related care provided to children (n = 29) during HSCT therapy by their healthcare providers (n = 10). Semi-structured interviews were also conducted with healthcare providers (n = 14).

RESULTS

The effectiveness of pain management interventions was hindered by the multifactorial nature of pain children experienced, a gap in the provision of psychosocial interventions for pain and a lack of evidence-based guidelines for the sustained, and often long-term, administration of opioids and adjuvant medications. Misconceptions were demonstrated by healthcare providers about escalating pain management according to pain severity and differentiating between opioid tolerance and addiction. Parents were active in the management of pain for children, especially the provision of nonpharmacological interventions. Collaboration with external pain services and the impact of caring for children in protective isolation delayed timely management of pain.

CONCLUSIONS

There is a pressing need to create evidence-based supportive care guidelines for managing pain post transplantation to optimize children's relief from pain. If parents and children are to be involved in managing pain, greater efforts must be directed toward building their capacity to make informed decisions.

Changes in von Willebrand Factor Multimers, Concentration, and Function During Pediatric Extracorporeal Membrane Oxygenation

OBJECTIVES

To investigate changes in von Willebrand factor (VWF) concentration, function, and multimers during pediatric extracorporeal membrane oxygenation (ECMO) and determine whether routine monitoring of VWF during ECMO would be useful in predicting bleeding.

DESIGN

Prospective observational study of pediatric ECMO patients from April 2017 to May 2019.

SETTING

The PICU in a large, tertiary referral pediatric ECMO center.

PATIENTS

Twenty-five neonates and children (< 18 yr) supported by venoarterial ECMO.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Arterial blood samples were collected within 24 hours pre-ECMO, daily for the first 5 days of ECMO, every second day until decannulation, and 24 hours post-ECMO. The STA R Max analyzer was used to measure VWF antigen (VWF:Ag) and ristocetin cofactor (VWF:RCo) activity. VWF collagen binding (VWF:CB) was measured using an enzyme-linked immunosorbent assay. VWF multimers were measured using the semi-automated Hydragel 11 VWF Multimer assay. Corresponding clinical data for each patient was also recorded. A total of 25 venoarterial ECMO patients were recruited (median age, 73 d; interquartile range [IQR], 3 d to 1 yr). The median ECMO duration was 4 days (IQR, 3-8 d) and 15 patients had at least one major bleed during ECMO. The percentage of high molecular weight multimers (HMWM) decreased and intermediate molecular weight multimers increased while patients were on ECMO, irrespective of a bleeding status. VWF:Ag increased and the VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag ratios decreased while patients were on ECMO compared with the baseline pre-ECMO samples and healthy children.

CONCLUSIONS

Neonates and children on ECMO exhibited a loss of HMWM and lower VWF:CB/VWF:Ag and VWF:RCo/VWF:Ag ratios compared with healthy children, irrespective of major bleeding occurring. Therefore, monitoring VWF during ECMO would not be useful in predicting bleeding in these patients and changes to other hemostatic factors should be investigated to further understand bleeding during ECMO.

Using an electronic medical record patient portal for warfarin self-management: Empowering children and parents

Background

Many children taking warfarin perform their international normalized ratio (INR) at home, with results phoned to a clinician who instructs warfarin dosing. Data suggest that parents can be supported to make warfarin dosing decisions themselves, a process known as patient self-management (PSM).

Objectives

This study aimed to determine the suitability and acceptability of warfarin PSM in children using the Epic Patient Portal.

Methods

Children currently performing INR patient self-testing were eligible. Participation involved an individualized education session, adherence to the PSM program, and participation in phone interviews. Clinical outcomes (INR time in therapeutic range and safety outcomes), patient portal functionality, and family experience were assessed. The hospital human research ethics committee approved the study and consent was obtained from parents/guardians.

Results

Twenty-four families undertook PSM. The median age of children was 11 years and all children had congenital heart disease. A median of 13 INRs was uploaded to the portal per family (range, 8-47) across a 10-month period. Before PSM, the mean time the INR was in therapeutic range was 71%; this increased to 79.9% during PSM (difference: P < .001). No adverse events were encountered. Eight families participated in a phone interview. The major theme identified was empowerment; minor themes that emerged included "gaining knowledge," "trust and responsibility builds confidence," "saving time," and "resources as a safety net."

Conclusion

This study demonstrates that communication via the Epic Patient Portal is satisfactory to families and offers a suitable option for PSM for children. Importantly, PSM empowers and builds confidence in families to facilitate management of their child's health.

Exploring the impact of the COVID-19 environment on nursing delivery of family-centred care in a paediatric hospital

AIMS AND OBJECTIVES

To understand how the pandemic environment impacted the delivery of FCC of children and families from a nursing perspective in a major tertiary paediatric hospital.

BACKGROUND

Family-centred care (FCC) is a well-established framework to promote parental involvement in every aspect of a child's hospitalization, however, rules and restrictions in place during the COVID-19 pandemic affected the ways in which Family-centred Care could be delivered in practice.

DESIGN

This is a qualitative exploratory descriptive study to elicit the perspective of paediatric nurses delivering care to children in a hospital during the COVID-19 pandemic in Victoria, Australia.

METHODS

Nurses from all subspecialties in a tertiary paediatric hospital were invited to participate in virtual focus groups to discuss their experience of delivering FCC during the COVID-19 pandemic. Focus groups were recorded and transcribed, then analysed using Framework Analysis.

RESULTS

Nineteen nurses participated across seven focus groups during June and July 2020. The four themes-Advocating with empathy, Enabling communication, Responding with flexibility, and Balancing competing considerations-and the eight subthemes that were generated, outline how nurses deliver FCC, and how these FCC actions were impacted by the COVID-19 environment and the related hospital restrictions.

CONCLUSION

This study documents the experiences, resilience and resourcefulness of paediatric nurses in Australia during the COVID-19 pandemic as well as moving Family-centred Care from a theoretical framework into a practical reality.

IMPACT

The findings from this study should inform consideration of the impacts of public health policies during infectious disease outbreaks moving forward. In addition by describing the core actions of Family-centred Care, this study has implications for educational interventions on how to translate FCC theory into practice. No public or patient contribution as this study explored nursing perceptions only.

Behavioural emergencies in a paediatric hospital environment

AIM

Aggression and high-risk behaviours triggered by children in paediatric hospitals are increasing globally. There is a paucity of research describing behavioural emergencies in paediatric acute care settings.

METHODS

We conducted a 1-year retrospective study of behavioural emergencies that triggered an emergency response team attendance in a quaternary paediatric hospital.

RESULTS

In 2018, 218 children triggered 1050 behavioural emergencies, which utilised 386 h of the emergency response team time. Thirty-three (15%) children triggered more than five activations each (range 6-272) and nearly half (16) were children with autism spectrum disorder or intellectual disability. More than 80% of children who triggered an emergency team response also had at least one psychiatric co-morbidity.

CONCLUSIONS

Behavioural emergencies, by definition, put staff, children or their families at risk. They occur frequently in hospital with some children repeating these behaviours despite allocation of resources and expertise. New approaches to prevention and amelioration are needed.

The influence of contextual factors on children's communication of pain during pediatric Haematopoietic Stem Cell Transplantation: A qualitative case study

PURPOSE

The aim of this study was to describe how contextual factors related to the clinical setting of a pediatric HSCT unit influenced children's communication of pain to their health-care providers and parents during hospitalization.

DESIGN AND METHODS

A qualitative case study design was conducted in two-phases in a tertiary level pediatric HSCT unit. The Social Communication Model of Pain provided the conceptual framework for the study. In phase one participants were parents and phase two participants were health-care providers and children in a pediatric HSCT unit. Parents participated in semi-structured interviews at 30- and 90-days post-transplantation regarding their child's communication of pain. Naturalistic observations of children receiving clinical care were conducted and health-care providers participated in semi-structured interviews.

RESULTS

Children extensively denied pain to their parents and health-care providers. When children did communicate pain, they were motivated by a need to seek interventions for their pain. Children's willingness to communicate pain was influenced by the physiological impact of HSCT therapy, their previous experiences of pain, their relationship with parents and health-care providers and parents and an environment of fear and uncertainty.

CONCLUSIONS

There is a pressing need for child-centric approaches to support children to communicate their pain experiences to overcome the limitations imposed by the complexity of their medical treatment and the clinical environment in which they receive healthcare.

PRACTICE IMPLICATIONS

In the context of HSCT therapy children may not communicate pain until pain is severe, and no longer bearable, or outright deny the presence of pain.

Coagulation in pediatric extracorporeal membrane oxygenation: A systematic review of studies shows lack of standardized reporting

Objectives

Extracorporeal membrane oxygenation (ECMO) involves complex coagulation management and frequent hemostatic complications. ECMO practice between centers is variable. To compare results between coagulation studies, standardized definitions and clear documentation of ECMO practice is essential. We assessed how study population, outcome definitions, and ECMO‐, coagulation‐, and transfusion‐related parameters were described in pediatric ECMO studies.

Data sources

Embase, Medline, Web of Science, Cochrane Library and Google Scholar.

Study selection

English original studies of pediatric ECMO patients describing hemostatic tests or outcome.

Data extraction

Eligibility was assessed following PRISMA guidelines. Study population, outcome and ECMO‐, coagulation, and transfusion parameters were summarized.

Data synthesis

A total of 107 of 1312 records were included. Study population parameters most frequently included (gestational) age (79%), gender (60%), and (birth) weight (59%). Outcomes, including definitions of bleeding (29%), thrombosis (15%), and survival (43%), were described using various definitions. Description of pump type, oxygenator and cannulation mode occurred in 49%, 45%, and 36% of studies, respectively. The main coagulation test (53%), its reference ranges (49%), and frequency of testing (24%) were the most prevalent reported coagulation parameters. The transfusion thresholds for platelets, red blood cells, and fibrinogen were described in 27%, 18%, and 18% of studies, respectively.

Conclusions

This systematic review demonstrates a widespread lack of detail or standardization of several parameters in coagulation research of pediatric ECMO patients. We suggest several parameters that might be included in future coagulation studies. We encourage the ECMO community to adopt and refine this list of parameters and to use standardized definitions in future research.

Current and emerging technologies for the timely screening and diagnosis of neonatal jaundice

Neonatal jaundice is one of the most common clinical conditions affecting newborns. For most newborns, jaundice is harmless, however, a proportion of newborns develops severe neonatal jaundice requiring therapeutic interventions, accentuating the need to have reliable and accurate screening tools for timely recognition across different health settings. The gold standard method in diagnosing jaundice involves a blood test and requires specialized hospital-based laboratory instruments. Despite technological advancements in point-of-care laboratory medicine, there is limited accessibility of the specialized devices and sample stability in geographically remote areas. Lack of suitable testing options leads to delays in timely diagnosis and treatment of clinically significant jaundice in developed and developing countries alike. There has been an ever-increasing need for a low-cost, simple to use screening technology to improve timely diagnosis and management of neonatal jaundice. Consequently, several point-of-care (POC) devices have been developed to address this concern. This paper aims to review the literature, focusing on emerging technologies in the screening and diagnosing of neonatal jaundice. We report on the challenges associated with the existing screening tools, followed by an overview of emerging sensors currently in pre-clinical development and the emerging POC devices in clinical trials to advance the screening of neonatal jaundice. The benefits offered by emerging POC devices include their ease of use, low cost, and the accessibility of rapid response test results. However, further clinical trials are required to overcome the current limitations of the emerging POC's before their implementation in clinical settings. Hence, the need for a simple to use, low-cost POC jaundice detection technology for newborns remains an unsolved challenge globally.

Platelet Phenotype and Function Changes With Increasing Duration of Extracorporeal Membrane Oxygenation

OBJECTIVES

To investigate platelet pathophysiology associated with pediatric extracorporeal membrane oxygenation (ECMO).

DESIGN

Prospective observational study of neonatal and pediatric ECMO patients from September 1, 2016, to December 31, 2019.

SETTING

The PICU in a large tertiary referral pediatric ECMO center.

PATIENTS

Eighty-seven neonates and children (< 18 yr) supported by ECMO.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Arterial blood samples were collected on days 1, 2, and 5 of ECMO and were analyzed by whole blood flow cytometry. Corresponding clinical data for each patient was also recorded. A total of 87 patients were recruited (median age, 65 d; interquartile range [IQR], 7 d to 4 yr). The median duration of ECMO was 5 days (IQR, 3-8 d) with a median length of stay in PICU and hospital of 18 days (IQR, 10-29 d) and 35 days (IQR, 19-75 d), respectively. Forty-two patients (48%) had at least one major bleed according to a priori determined definitions, and 12 patients (14%) had at least one thrombotic event during ECMO. Platelet fibrinogen receptor expression decreased (median fluorescence intensity [MFI], 29,256 vs 26,544; p = 0.0005), while von Willebrand Factor expression increased (MFI: 7,620 vs 8,829; p = 0.0459) from day 2 to day 5 of ECMO. Platelet response to agonist, Thrombin Receptor Activator Peptide 6, also decreased from day 2 to day 5 of ECMO, as measured by binding with anti-P-selectin, PAC-1 (binds activated GPIIb/IIIa), and anti-CD63 monoclonal antibodies (P-selectin area under the curve [AUC]: 63.46 vs 42.82, respectively, p = 0.0022; PAC-1 AUC: 93.75 vs 74.46, p = 0.0191; CD63 AUC: 55.69 vs 41.76, p = 0.0020).

CONCLUSIONS

The loss of platelet response over time may contribute to bleeding during ECMO. These novel insights may be useful in understanding mechanisms of bleeding in pediatric ECMO and monitoring platelet markers clinically could allow for prediction or early detection of bleeding and thrombosis.

Experiences of Pain in Hospitalized Children During Hematopoietic Stem Cell Transplantation Therapy

Children undergoing hematopoietic stem cell transplantation (HSCT) are vulnerable to pain due to the intensity and toxicity of this treatment. An instrumental case study design of two qualitative phases was conducted to examine the pain experiences of hospitalized children during HSCT therapy and how contextual factors related to the pediatric HSCT environment influenced their experience of pain. The Social Communication Model of Pain provided the conceptual framework for the study. In Phase 1, semi-structured interviews were conducted with parents of a child undergoing HSCT therapy at two time points. Phase 2 was conducted as a naturalistic observational study of the clinical care provided to children and semi-structured interviews with health-care providers. Children experienced complex and multifaceted pain with physical, psychological, and contextual contributors. Understanding the many factors contributing to the child's pain experience can inform strategies to improve the management of pain during HSCT therapy.

GRADE notes: How to use GRADE when there is "no" evidence? A case study of the expert evidence approach

OBJECTIVES

One essential requirement of trustworthy guidelines is that they should be based on systematic reviews of the best available evidence. The GRADE Working Group has provided guidance for evaluating the certainty of evidence based on several domains. However, for many clinical questions, published evidence may be limited, too indirect or simply not exist. In this brief report (GRADE notes), we describe our method of developing evidence-based recommendations when publisheddirect evidence was lacking.

STUDY DESIGN AND SETTING

When direct published literature was absent, an expert evidence survey was administered to panel members about their unpublished observations and case series. Focus was on collecting data about cases and outcome, not panel opinions.

RESULTS

Out of 26 questions prioritized by the panel for pediatric venous thromboembolism, 12 had no, very limited, or very low certainty of evidence to inform them. The panel survey was administered for these questions.

CONCLUSIONS

Areas of sparse evidence often reflect key questions that are critical to address in clinical practice guidelines due to the uncertainty among health care providers. The expert evidence approach used in this study is one method for panels totransparently deal with the lack of published evidence to directly inform recommendations.

Mechanism of bilirubin elimination in urine: insights and prospects for neonatal jaundice

Despite a century of research, bilirubin metabolism and the transport mechanisms responsible for homeostasis of bilirubin in serum remain controversial. Emerging evidence on the hepatic membrane transporters and inherited disorders of bilirubin metabolism have contributed to a greater understanding of the various steps involved in bilirubin homeostasis and its associated excretory pathways. We discuss these recent research findings on hepatic membrane transporters and evaluate their significance on the newborn bilirubin metabolism and excretion. New insights gained speculate that a proportion of conjugated bilirubin is excreted via the renal system, as an alternative to the intestinal excretion, even in normal physiological jaundice with no associated pathological concerns. Finally, this paper discusses the clinical relevance of targeting the altered renal excretory pathway, as bilirubin in urine may hold diagnostic importance in screening for neonatal jaundice.

Barriers and Facilitators to Seeking Sleep Solutions for Children With Cerebral Palsy: A Qualitative Study

Background: Published evidence to date suggests that sleep problems are common in children with cerebral palsy (CP). This qualitative study is a follow up to a previously published quantitative phase on the experience and impact of sleep problems in this population. Aims: The aim of this study was to explore the experience and impact of sleep disturbance and seeking of sleep solutions for parents of school aged children with CP. Materials and Methods: Semi-structured 19 qualitative interviews were conducted with parents of children with CP aged 6-12 years. Interview data were transcribed verbatim and the thematic analysis techniques by Braun and Clarke was used to identify themes. Results: Thematic analysis identified 7 themes: (1) My Child Doesn't Fit into the Box, (2) A Mother's Ears are Always On, (3) Sleep Disturbance is like Water Torture, (4) Sleep is One of Many Spot Fires, I Put it on the Backburner, (5) Luck, Money or Jumping Up and Down, (6) There is Never One Silver Bullet and (7) Help: The Earlier the Better. The key finding was that parents of children with CP often described their child's needs being distinct from what is provided by systems and services. Conclusion: Parents face significant challenges sourcing effective sleep solutions for their child with CP. Sleep is often not a priority for either the parent or the clinician as other health problems take precedence. Parents reflected that early sleep intervention for their child was or would have been helpful. The barriers and facilitators to sleep care identified in this study should be used to inform clinical change in care for children with CP. Sleep needs to be prioritized in healthcare for children.

Simulation-based education for teaching aggression management skills to health care providers in the acute health care setting: a systematic review protocol

BACKGROUND

Clinical aggression episodes, that is aggression and externalising behaviours that create risk, in acute care hospitals are increasing. Acute care staff are often not confident or trained in the management of aggression. Various aggression management training formats have been described in practice including face to face training, written learning resources, web- and media-based training resources, and simulation training. The aim of this systematic review is to assess whether simulation-based training is effective in increasing de-escalation knowledge, skills, and behaviour of staff working in the acute care setting.

METHODS

We designed and registered a study protocol for a systematic review of studies evaluating simulation-based training for the management of patients with aggression. We will include randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, and observational studies including health care professionals and trainees in acute health care settings. Comprehensive searches will be conducted in the following databases (from January 1980 onwards): PubMed, MEDLINE, PsycINFO, CINAHL, and the Cochrane Library. The reference lists of selected studies, trial registers, and leading journals will also be searched. Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential discrepancies will be resolved through discussion. The primary outcomes will include patient outcomes (e.g. frequency of clinical aggression), quality of care (e.g. frequency of emergency situations, physical/chemical/mechanical restraint), and adverse effects (e.g. patient/family complaints, patient harms, staff harms). Secondary outcomes will include workplace resource use, health care provider-related outcomes, knowledge (de-escalation techniques), performance, attitudes, and satisfaction. The study methodological risk of bias will be appraised using appropriate tools. A narrative synthesis will be performed for included studies. If feasible, we will conduct random-effects meta-analysis of data. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g. participant characteristics, interventions, and follow-up).

DISCUSSION

This systematic review will identify, evaluate, and integrate the evidence on simulation-based training programmes for acute care health professionals on managing clinical aggression. The results of this study will inform the implementation of effective training strategies. Implications for future research will be discussed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020151002.

Simulation-based education to promote confidence in managing clinical aggression at a paediatric hospital

BACKGROUND

An increasing number of incidents involving aggressive behaviour in acute care hospitals are being witnessed worldwide. Acute care hospital staff are often not trained or confident in managing aggression. Competent management of clinical aggression is important to maintain staff and patient safety. Training programmes for acute care staff are infrequently described in the literature and rarely reported for paediatric staff. Simulation training allows practice of skills without patient risk and may be more effective than traditional teaching formats for aggression management.

AIM AND DESIGN

The aim of this proof of concept study was to develop a simulation-based education session on aggression management for acute care paediatric staff based on best practice principles, to evaluate the acceptability of this training programme and to gain an understanding of the impact of the training on participants' perceived confidence in managing clinical aggression. Two separate simulation exercises were delivered as a 2-h component of a hospital management of clinical aggression (MOCA) training day. Participants completed a written survey immediately prior to, at completion of the simulation-based group training, and at 3-6 months following the simulation training.

FINDINGS

Nine training days were conducted in 2017 for nursing, medical, allied health, education and security staff with a total of 146 participants (83% were acute care nurses). Two thirds (68%) of participants had experienced clinical aggression as part of their routine work, with 51% overall reporting a lack of confidence managing these patients. Immediately following the simulation training, 80% of all participants reported feeling more confident in managing clinical aggression, 47% reported a 1-point increase in confidence, whilst 33% of participants reported a 2- or 3-point increase. At 3-6 months post-training, 66% of respondents (N = 44) reported continued confidence in managing aggression with 100% of participants stating they would recommend simulation training to colleagues.

CONCLUSIONS

Simulation training is an acceptable method of training and shows promise to improve staff-perceived confidence for managing behavioural emergencies in acute paediatric health care settings. In addition, there were potential enduring positive impacts at 3 months after the study. Whilst resource and time intensive, further research assessing the benefits of utilising simulation training in this setting is warranted in order to minimise staff burn-out and improve outcomes for these very vulnerable patients.

Revisiting the Pharmacology of Unfractionated Heparin

Unfractionated heparin (UFH) is a commonly used anticoagulant therapy for the acute treatment and prevention of thrombosis. Its short duration of action, reversibility of effect by protamine sulfate, and extensive clinical experience are some of the advantages that support its use. However, the choice of dose and dosing regimen of UFH remains challenging for several reasons. First, UFH has a narrow therapeutic window and wide variability in the dose-response relationship. Second, its pharmacodynamic (PD) properties are difficult to characterise owing to the complex multidimensional mechanisms of interaction with the haemostatic system. Third, the complex heterogeneous chemical composition of UFH precludes precise characterisation of its pharmacokinetic (PK) properties. This review provides a comprehensive mechanistic approach to the interaction of UFH with the haemostatic system. The effect of chemical structure on its PK and PD properties is quantitatively described, and a framework for characterisation of the dose-response relationship of UFH for the purpose of dose optimisation is proposed.

Sleep problems and solution seeking for children with cerebral palsy and their parents

AIM

Sleep problems are common in school-aged children with cerebral palsy (CP). Despite the significant impact of sleep disturbance and deprivation, there is a paucity of research in the area. The aims of this study were to (i) investigate the frequency of sleep problems in children with CP and their parents and (ii) understand what happens when parents ask for help with sleep problems from their health-care professionals.

METHODS

This was a prospective cohort study using an online survey sent to parents/primary care givers of children with CP aged 6-12 years recruited through the Victorian Cerebral Palsy Register. The following sleep assessment tools: The Children's Sleep Habits Questionnaire, the Pittsburgh Sleep Quality Index and the Gross Motor Function Classification System Parent Rating Tool were administered along with custom-designed questions that were informed by a preceding qualitative scoping study.

RESULTS

Complete data sets were received from 126 parents/care givers. Almost half (46%) of the parents reported their child had sleep problems. Of the 64 parents who reported seeking help for a child's sleep problem, only 21 indicated that their attempt was successful. If a child had poor sleep, the parent was more likely to have a sleep problem than parents who did not report poor child sleeping.

CONCLUSION

Sleep problems are common in children with CP and their parents. Parents do not always seek help, and those who do may not find an effective solution. Future research should explore how sleep problems can be effectively prioritised for children with CP and their parents/care givers.

Vaccination in people with disability: a review

People with disabilities are vulnerable to complications from vaccine-preventable diseases, and every effort should be made to ensure equitable access to immunization for this population. This paper aims to summarize the research on immunizations in people with disabilities, in order to ensure a comprehensive understanding of knowledge in this area and direct further research. The literature is weighted towards coverage data that is difficult to synthesize because of the different definitions of disability, and the variety of settings, vaccinations and age groups across the studies. In-depth qualitative data and data from a variety of health-care providers and people with disability is notably lacking. This is vital to redress in order to develop effective immunization interventions in this population.

Medication error trends and effects of person-related, environment-related and communication-related factors on medication errors in a paediatric hospital

AIM

This study aimed to examine reported medication error trends in an Australian paediatric hospital over a 5-year period and to determine the effects of person-related, environment-related and communication-related factors on the severity of medication outcomes. In particular, the focus was on the influence of changes to a hospital site and structure on the severity of medication errors.

METHODS

A retrospective clinical audit was undertaken over a 5-year period of paediatric medication errors submitted to an online voluntary reporting system of an Australian, tertiary, public teaching paediatric hospital. All medication errors submitted to the online system between 1 July 2010 and 30 June 2015 were included.

RESULTS

A total of 3340 medication errors was reported, which corresponded to 0.56% medication errors per combined admissions and presentations or 5.73 medication errors per 1000 bed days. The most common patient outcomes related to errors requiring monitoring or an intervention to ensure no harm occurred (n = 1631, 48.8%). A new hospital site and structure had 0.354 reduced odds of producing medication errors causing possible or probable harm (95% confidence interval 0.298-0.421, P < 0.0001). Patient and family involvement had 1.270 increased odds of identifying medication errors associated with possible or probable harm compared with those causing no harm (95% confidence interval 1.028-1.568, P = 0.027). Interrupted time series analyses showed that moving to a new hospital site and structure was associated with a reduction in reported medication errors.

CONCLUSION

Encouraging child and family involvement, facilitating hospital redesign and improving communication could help to reduce the harm associated with medication errors.

Education needs of nurses in thrombosis and hemostasis: An international, mixed-methods study

BACKGROUND

The need for a more integrated, multidisciplinary approach to care for individuals with bleeding or clotting disorders has been highlighted in recent years. Evidence-based education adapted to nurses' needs is essential for a successful evolution. However, limited data currently exist on the clinical challenges nurses face in this specialty area.

OBJECTIVES

Identify barriers and challenges faced by specialty nurses, and determine possible causes, to develop appropriate educational interventions.

METHODS

A mixed-methods study, combining qualitative (semi-structured interviews) and quantitative (online survey) data was conducted on the challenges experienced by hemostasis nurses in nine countries (Argentina, Australia, Canada, China, France, Germany, Spain, the UK, and the US), and deployed in five languages (English, French, German, Mandarin, and Spanish). Qualitative data were analyzed using thematic analysis. Quantitative data were analyzed using frequency tables, chi-squares and standard deviations.

RESULTS

Participants (n = 234) included nurses (n = 212; n = 22 qualitative; n = 190 quantitative); and patients receiving care for bleeding or clotting conditions or their caretakers (n = 22 qualitative phase only). Through triangulated data analysis, six challenging areas emerged: (a) Understanding of von Willebrand disease (VWD); (b) Anticoagulant safety profile in specific patients; (c) Understanding the treatment of patients with inhibitors; (d) Patient risk assessments; (e) Individualization of care and communication with patients; and (f) Accessing and implementing relevant professional education.

CONCLUSIONS

This needs assessment provides a comprehensive illustration of the current challenges faced by nurses in the field of bleeding and clotting disorders, and indicates where gaps in skills, knowledge or confidence would benefit from nurse-specific educational programming.

Management of thrombosis in children and neonates: practical use of anticoagulants in children

Venous thrombosis (VTE) in children and neonates presents numerous management challenges. Although increasing in frequency, VTE in children and neonates is still uncommon compared with adults. The epidemiology of VTE is vastly different in neonates vs children vs adolescents vs adults. In reality, pediatric thrombosis should be viewed as a multitude of rare diseases (eg, renal vein thrombosis, spontaneous thrombosis, catheter-related thrombosis, cerebral sinovenous thrombosis), all requiring different approaches to diagnosis and with different short- and long-term consequences, but linked by the use of common therapeutic agents. Further, children have fundamentally different physiology in terms of blood flow, developmental hemostasis, and, likely, endothelial function. The American Society of Hematology 2017 Guidelines for Management of Venous Thromboembolism: Treatment of Pediatric VTE provides up-to-date evidence-based guidelines related to treatment. Therefore, this article will focus on the practical use of therapeutic agents in the management of pediatric VTE, especially unfractionated heparin, low-molecular-weight heparin, and oral vitamin K antagonists, as the most common anticoagulants used in children. Direct oral anticoagulants (DOACs) remain in clinical trials in children and should not be used outside of formal trials for the foreseeable future.

American Society of Hematology 2018 Guidelines for management of venous thromboembolism: treatment of pediatric venous thromboembolism

BACKGROUND

Despite an increasing incidence of venous thromboembolism (VTE) in pediatric patients in tertiary care settings, relatively few pediatric physicians have experience with antithrombotic interventions.

OBJECTIVE

These guidelines of the American Society of Hematology (ASH), based on the best available evidence, are intended to support patients, clinicians, and other health care professionals in their decisions about management of pediatric VTE.

METHODS

ASH formed a multidisciplinary guideline panel that included 2 patient representatives and was balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including updating or performing systematic evidence reviews (up to April of 2017). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 30 recommendations, covering symptomatic and asymptomatic deep vein thrombosis, with specific focus on management of central venous access device-associated VTE. The panel also addressed renal and portal vein thrombosis, cerebral sino venous thrombosis, and homozygous protein C deficiency.

CONCLUSIONS

Although the panel offered many recommendations, additional research is required. Priorities include understanding the natural history of asymptomatic thrombosis, determining subgroup boundaries that enable risk stratification of children for escalation of treatment, and appropriate study of newer anticoagulant agents in children.

Anticoagulant prophylaxis and therapy in children: current challenges and emerging issues

This review is aimed at describing the unique challenges of anticoagulant prophylaxis and treatment in children, and highlighting areas for research for improving clinical outcomes of children with thromboembolic disease. The evidence presented demonstrates the challenges of advancing the evidence base informing optimal management of thromboembolic disease in children. Recent observational studies have identified risk factors for venous thromboembolism in children, but there are few interventional studies assessing the benefit-risk balance of using thromboprophylaxis in risk-stratified clinical subgroups. A risk level-based framework is proposed for administering mechanical and pharmacological thromboprophylaxis. More research is required to refine the assignment of risk levels. The anticoagulants currently used predominantly in children are unfractionated heparin, low molecular weight heparin, and vitamin K antagonists. There is a paucity of robust evidence on the age-specific pharmacology of these agents, and their efficacy and safety for prevention and treatment of thrombosis in children. The available literature is heterogeneous, reflecting age-specific differences, and the various clinical settings for anticoagulation in children. Monitoring assays and target ranges are not well established. Nevertheless, weight-based dosing appears to achieve acceptable outcomes in most indications. Given the limitations of the classical anticoagulants for children, there is great interest in the direct oral anticoagulants (DOACs), whose properties appear to be particularly suitable for children. All DOACs currently approved for adults have Pediatric Investigation Plans ongoing or planned. These are generating age-specific formulations and systematic dosing information. The ongoing pediatric studies still have to establish whether DOACs have a positive benefit-risk balance in the various pediatric indications and age groups.

Point of care monitoring of oral anticoagulant therapy in children: comparison of CoaguChek Plus and Thrombotest methods with venous international normalised ratio

This paper reports the outcome of a research protocol aimed at optimising warfarin monitoring in a tertiary pediatric centre. The Thrombotest™ INR was the standard monitoring test employed to manage oral anticoagulant therapy in children at the Royal Children’s Hospital (RCH), Melbourne. This study compares the results of this standard method to the novel CoaguChek® INR monitor and the “gold standard” technique of venous INR sampling. The objectives were to determine 1) if point-of-care techniques of measuring the INR (Thrombotest and CoaguChek) are accurate and reliable compared to INR results obtained from venous sampling, processed in an accredited laboratory, and 2) if INR results generated by POC devices can be safely used to manage oral anticoagulant therapy in children. 18 children (10 females and 8 males) participated in the study. Ages ranged from 9 months to 21 years (Mean 11.9 years; SD 5.03 years). The agreement between CoaguChek and venous INR measurements (r = 0.885) was shown to be higher compared to Thrombotest and venous INR (r = 0.700). Compared to the venous INR, values obtained with Coaguchek and Thrombotest crossed into or out of the therapeutic range in 25% and 36% of cases respectively. In 88% of the CoaguChek cases and 57% Thrombotest cases, the difference from the venous result was less than 0.5. The CoaguChek method of INR monitoring is a more accurate and reliable method compared to Thrombotest, in the pediatric population tested, and can be safely used to manage oral anticoagulant therapy in children.

Point-of-care monitoring of oral anticoagulation therapy in children

Point-of-care (POC) monitoring of oral anticoagulation has been widely adopted in both paediatric and adult patients. A new POC system, the CoaguChek XS® has recently been developed to measure the international normalised ratio (INR) and may offer significant advantages. The CoaguChek XS® utilises a new method of electrochemical clot detection based on thrombin generation. This system has not been previously evaluated in children with reference to the laboratory gold standard, the prothrombin time using reference thromboplastin. It was the objective to compare values obtained by the CoaguChek XS® system with both the venous INR and the gold standard for anticoagulant monitoring, prothrombin time with reference thromboplastin (rTF/95).To evaluate the impact of testing using the Coagu-Chek XS® on clinical anticoagulant dosing decisions. Fifty paired venous INR and capillary CoaguChek XS® results were obtained from 31 children (aged up to 16 years).The laboratory gold standard, a manual prothrombin time with reference thromboplastin (rTF/95) was additionally performed on 26 samples. Correlation between the CoaguChek XS® result and the venous INR was r= 0.810. Agreement between the CoaguChek XS result and the reference INR was shown to be higher (r=0.95), in the subset analysed by this method. Correlation between the venous INR and reference INR was r=0.90. Despite changes to the methodology of testing with the CoaguChek XS® POC monitoring system, the accuracy of this method when compared with both the venous INR and gold standard reference INR was satisfactory. This resulted in infrequent changes to clinical decision making regarding anticoagulation

Age is a determinant factor for measures of concentration and effect in children requiring unfractionated heparin

Previous studies investigating continuous unfractionated heparin (UFH) therapy report age-related differences in UFH response in children, as measured by APTT and anti-Xa assay. This study determined the age-related response following administration of a single UFH bolus of 75–100 IU/kg in children. Venous blood samples were collected from children (n=56) at 15, 30, 45 and 120 minutes post-UFH. Anti-Xa, anti-IIa, APTT, TCT and protamine titration were performed on all samples. Age-dependent differences in the effect and concentration of UFH were identified for the anti-Xa, anti-IIa and protamine titration as-says, respectively. In addition, a trend suggesting a proportional increase in anti-Xa and anti-IIa-mediated UFH effect with age was evident. Logistic regression demonstrated an increase in protamine titration of 0.6 IU/ml for every year of age in samples collected 15 minutes post-UFH. UFH-mediated anti-IIa activity was reduced compared to anti-Xa activity across childhood, with a two-fold increase in anti-Xa to anti-IIa ratio in infants less than one year of age compared to teenagers in the setting of high UFH concentrations. This study demonstrates that the previously reported age-dependent response to UFH occurs in the context of an age-dependent serum concentration of UFH. The trend toward increased UFH serum concentration and anticoagulant activity with age may be related to short-term differences in UFH binding to coagulant and competitive plasma proteins in vivo.

Principles and theory guiding development and delivery of patient education in disorders of thrombosis and hemostasis: Reviewing the current literature

Prior work regarding patient education has identified the importance of using learning theory and educational models to develop and deliver content that will improve patient outcomes. Current literature appears to examine implementation of teaching strategies without clear identification of educational principles. This review aimed to identify educational principles and theory currently utilized in the planning and delivery of patient education in disorders of thrombosis and hemostasis. The majority of articles reviewed evaluated the impact of educational interventions on patient outcomes; links between educational principles and changes in outcomes was lacking. Few articles clearly referenced theory in development of patient education; fewer focussed on the population of interest. The lack of literature demonstrates the need for multi-center collaborative research aimed at generation of an improved level of evidence regarding the most effective theoretical framework for the development, delivery and evaluation of patient education for patients with disorders of thrombosis and hemostasis. Once a theoretical framework for patient education is developed and tested, the unique contribution of patient education to both knowledge and clinical outcomes can be robustly evaluated.

Novel perspectives on diagnosis and clinical significance of the post-thrombotic syndrome in children

INTRODUCTION

Given the increase in venous thromboembolic events (VTE) in children, the incidence, diagnosis and management of post thrombotic syndrome (PTS) in children is of increasing interest. Current challenges facing clinicians caring for children with VTE is the limited evidence of the long-term outcomes for this cohort; specifically the significance and potential functional impairment associated with PTS.

AREAS COVERED

This paper reviews the current evidence to elucidate the risk factors for PTS in children, methods for diagnosis and management of PTS in children (aged less than 18 years). Medline, Cinahl and PsycINFO database searches were undertaken using key search terms. Priority areas in need of further research are highlighted. Expert commentary: The two paediatric PTS assessment tools currently in use have been acknowledged to overcall the incidence of mild PTS in children. A PTS tool's ability to distinguish between clinically significant PTS and mild PTS is crucial. Variation in how PTS has been reported in children across the literature suggests that the real incidence of moderate and /or clinically significant PTS in children is unknown. Furthermore, evidence is lacking about the functional impairment experienced by children with clinically significant PTS and what this means for their long-term health.

Difficulties with assessment and management of an infant's distress in the postoperative period: Optimising opportunities for interdisciplinary information-sharing

OBJECTIVES

The importance of accurate paediatric patient assessment is well established but under-utilised in managing postoperative medication regimens.

METHODS

Data for this case report were collected through observations of clinical practice, conduct of interviews, and retrieval of information from the medical record. This case report involving a hospitalised 1-year-old boy demonstrates the difficulties associated with assessing and managing postoperative distress, including pain and other clinical conditions related to the surgical procedure.

RESULTS

Postoperatively, there were difficulties in managing pain and an episode of over-sedation, occasioning opiate reversal with naloxone. In addition, he had decreasing oxygen saturation and increased work of breathing. X-ray showed changes consistent with either atelectasis or aspiration, and he was commenced on antibiotics. The patient experienced respiratory distress and required intervention from the medical emergency team.

CONCLUSION

This case demonstrated the importance of comprehensive assessment and careful consideration of alternative causes of an infant's distress using the results of assessment tools to aid decision-making. Communication moderates effective patient care, and more favourable outcomes could be achieved by optimising interdisciplinary information-sharing.

Prehospital Emergency Care in Childhood Arterial Ischemic Stroke

BACKGROUND AND PURPOSE

Immediately calling an ambulance is the key factor in reducing time to hospital presentation for adult stroke. Little is known about prehospital care in childhood arterial ischemic stroke (AIS). We aimed to determine emergency medical services call-taker and paramedic diagnostic sensitivity and to describe timelines of care in childhood AIS.

METHODS

This is a retrospective study of ambulance-transported children aged <18 years with first radiologically confirmed AIS, from 2008 to 2015. Interhospital transfers of children with preexisting AIS diagnosis were excluded.

RESULTS

Twenty-three children were identified; 4 with unavailable ambulance records were excluded. Nineteen children were included in the study. Median age was 8 years (interquartile range, 3-14); median Pediatric National Institutes of Stroke Severity Scale score was 8 (interquartile range, 3-16). Emergency medical services call-taker diagnosis was stroke in 4 children (21%). Priority code 1 (lights and sirens) ambulances were dispatched for 13 children (68%). Paramedic diagnosis was stroke in 5 children (26%), hospital prenotification occurred in 8 children (42%), and 13 children (68%) were transported to primary stroke centers. Median prehospital timelines were onset to emergency medical services contact 13 minutes, call to scene 12 minutes, time at scene 14 minutes, transport time 43 minutes, and total prehospital time 71 minutes (interquartile range, 60-85).

CONCLUSIONS

Emergency medical services call-taker and paramedic diagnostic sensitivity and prenotification rates are low in childhood AIS.

Providing opportunistic immunisations for at-risk inpatients in a tertiary paediatric hospital

Attaining high immunisation coverage rates for children with medical conditions is vital. The Royal Children's Hospital (RCH) Immunisation Service has the opportunity to check each inpatient's immunisation status and provide opportunistic vaccines and/or bring the Australian Childhood Immunisation Register (ACIR) up-to-date. This paper highlights that during admission, one quarter of children were not up-to-date with routine scheduled immunisations and 42% of those inpatients due or overdue for immunisation were vaccinated. The model of establishing routine checking of immunisation records and reminding hospital staff about immunisation can result in improvements in vaccination coverage. Healthcare providers have a responsibility to check immunisation status and offer vaccines when necessary; however, often there are missed opportunities to immunise. This paper demonstrates that having a dedicated Immunisation Service, a partnership with a relevant government agency, and effective collaboration with inpatient clinical teams, opportunistic immunisation can be achieved for inpatients.

Anti-activated factor II assay for monitoring unfractionated heparin in children: results of the HEARTCAT study

Essentials Unfractionated heparin has variable effects in children and therefore, monitoring is essential. A randomized controlled trial substudy investigating an anti-IIa assay in children was conducted. Anti-IIa values are lower in younger children, an effect more pronounced at low-dose heparin. Heparin effect on Xa and IIa is not equal, particularly in infants and after high-dose heparin.

SUMMARY

Background Unfractionated heparin (UFH) is used for the prophylaxis and treatment of thrombosis in children. Laboratory monitoring of UFH is needed to prevent over-anticoagulation or under-anticoagulation. Objectives To investigate the association between UFH dose and UFH effect as monitored with the anti-activated factor II (FIIa) assay, the relationship between anti-FIIa and anti-activated factor X (FXa) effects, and the influence of patient age and other factors on UFH effect. Patients and methods This was a randomized controlled trial in children during cardiac catheterization, comparing high-dose UFH (100 units kg-1 bolus) with low-dose UFH (50 units kg-1 bolus). Blood samples were drawn at baseline, and after 30 min, 60 min, and 90 min. For the purpose of this study, 49 children and 117 blood samples were evaluated. Results The anti-FIIa assay discriminated well between high-dose and low-dose UFH. Multiple regression demonstrated significant influences of UFH dose and age on anti-FIIa levels. Younger children had lower anti-FIIa levels than older children, an effect that was more pronounced with low-dose UFH. Anti-FXa/anti-FIIa ratios were equal with low-dose UFH. However, anti-FXa levels were relatively increased over anti-FIIa levels in infants and after high-dose UFH bolus administration. Conclusion The UFH effect on anti-FIIa levels is lower in infants than in older children. This influence of age appears to be dose-dependent, being more pronounced with low-dose UFH. Anti-FXa and anti-FIIa levels are not equal, particularly in infants and after high-dose UFH. Monitoring UFH solely with anti-FXa assays may not be sufficient in children, and the anti-FIIa assay may provide important complementary information.

Pain assessment and management in paediatric oncology: a cross-sectional audit

AIMS AND OBJECTIVES

To describe the pain assessment and management practices documented by health professionals within a tertiary-level Children's Cancer Centre and to evaluate how these practices were compared with international recommendations.

BACKGROUND

Children with cancer are vulnerable to pain due to the intensity of antineoplastic therapy. Therefore, it is imperative to ensure that current pain management practices provided to paediatric oncology inpatients are of a high quality.

DESIGN

A single-site cross-sectional audit.

METHODS

A 24-hour period of documented pain-related care in randomly selected inpatients of an Australian tertiary-level Children's Cancer Centre was examined. The current pain management practices were audited over a two-month period resulting in 258 episodes of pain-related care being reviewed.

RESULTS

Pain related to medical treatment for cancer was common (n = 146/258, 57%) and persistent. The presence of pain was not consistently recorded by health professionals (n = 75/146, 51%). Pain was mild (n = 26/75, 35%) and opioids were the mainstay of pain management interventions (n = 63/112, 56%). Adjuvants were an important component of pain management (n = 47/112, 42%), and nonpharmacological methods of managing pain were under-represented in this audit (n = 38/146, 26%). According to the Pain Management Index, pain was appropriately managed for the majority of children (n = 65/76, 87%).

CONCLUSIONS

Pain management practices did not fully reflect the recommendations of contemporary paediatric pain management. Due to limitations in the documentation of children's pain, it was difficult to determine the effectiveness of pain management interventions.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the ongoing problem of pain for children receiving antineoplastic therapy. It is recommended that health professionals routinely screen for the presence of pain during hospitalisation and assess the efficacy of pain-related care.

Development of a population pharmacokinetic-pharmacodynamic model of a single bolus dose of unfractionated heparin in paediatric patients

BACKGROUND

Unfractionated heparin (UFH) is the anticoagulant of choice in paediatric patients undergoing a variety of cardiac procedures. There are currently no population pharmacokinetic-pharmacodynamic (PKPD) models for UFH in paediatrics.

OBJECTIVE

The aim of the present study was to develop and evaluate a PKPD model of UFH in paediatrics.

METHODS

Data from 64 children who received 75-100 IU kg(-1) of UFH during cardiac angiography were analysed. Five blood samples were collected at baseline and at 15, 30, 45 and 120 min postdose. The UFH concentration was quantified using a protamine titration assay. The UFH effect was quantified using activated partial thromboplastin time (aPTT). A PKPD model was fitted using nonlinear mixed-effects modelling. Patient covariates such as gender, weight (WT) and fat-free mass (FFM) were tested. The final model was evaluated using the likelihood ratio test and visual predictive checks (VPCs).

RESULTS

A one-compartment model with linear elimination provided the best fit for the dose-concentration data. FFM was a significant covariate on clearance. A linear model provided the best fit for the concentration-effect data using aPTT as a biomarker for effect. The models performed well using VPCs. However, when used to simulate UFH infusion (at a much lower dose), the model overpredicted target aPTT responses.

CONCLUSIONS

A PKPD model to describe the time course of the UFH effect was developed in a paediatric population. FFM was shown to describe drug disposition well. However, when applied to smaller UFH infusion doses, the model overpredicted target aPTT responses. This unsuccessful extrapolation may be attributed to a possible nonlinear relationship for heparin PKPD.

Creating a journal club competition improves paediatric nurses' participation and engagement

BACKGROUND

To improve journal club participation, innovative approaches are required but few have been described. It was unknown if adding an element of competition, to an established journal club, would increase nurses' participation.

OBJECTIVE

To explore the impact on attendance and participation in a hospital-wide nursing journal club through the introduction of an element of competition.

DESIGN

A descriptive exploratory study.

SETTING AND PARTICIPANTS

An Australian specialist tertiary paediatric hospital with over 1600 nurses.

METHODS

In 2013, 12 hospital wards/departments were randomly assigned a month each to present journal club. Nurses were supported to evaluate an article according to a published framework. A predetermined rubric guided marking. Post competition, all hospital nurses received an anonymous online survey invitation. Demographic, Likert scale and qualitative data were collected. Questions elicited attitudes and perceived barriers or facilitators to participation in the journal club.

RESULTS

Compared to 2012, there was a statistically significant increase in journal club attendance (2013 median=20.5 [IQR=18.2, 27.7] vs. 2012 median=9 [IQR=6.5, 12.5], Mann-Whitney U test, p<0.01). Full online survey responses were received from 289/1674 (response rate 17.3%) of sent invitations (Non-Attendees n=224, Attendees n=65 (including 18 presenters). Overall, Attendees reported journal club had a positive impact on their professional engagement. Presenters rated the journal club format highly as it developed skills and increased their confidence in journal club presentation. Emergent themes were time and location, engagement, topics and content.

CONCLUSION

A competition format can increase nurses' journal club attendance and participation. Further work is required to establish applicability of this format to other settings.