Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods

BACKGROUND AND OBJECTIVES

Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months.

METHODS

We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children's hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures.

RESULTS

The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found.

CONCLUSIONS

Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.

Multi-institutional outcome study on the efficacy of closed-suction drainage of the scrotum in three-piece inflatable penile prosthesis surgery

Infection is a devastating complication of penile prosthesis surgery that occurs in approximately 2-5% of all primary inflatable penile primary implants in most series. Prevention of hematoma and swelling with closed-suction drains has been shown not to increase infection rate and yield an earlier recovery time. Despite the intuitive advantages of short-term closed-suction drainage in reducing the incidence of postoperative scrotal swelling and associated adverse effects, many urologists are reluctant to drain the scrotum because of a theoretical risk of introducing an infection. In conclusion, this study was undertaken to evaluate the incidence of infection in three-piece penile prosthesis surgery with scrotal closed-suction drainage. A retrospective review of 425 consecutive primary three-piece penile prosthesis implantations was performed at three institutions in New Jersey, Ohio, and Arkansas from 1998 to 2002. Following the prosthesis insertion, 10 French Round Blake (Johnson & Johnson) or, in a few cases, 10 French Jackson Pratt, closed-suction drains were placed in each patient for less than 24 h. All subjects received standard perioperative antibiotic coverage. Average age at implant was 62 y (range 24-92 y). Operative time (incision to skin closure) was less than 60 min in the vast majority of cases. There were a total of 14 (3.3%) infections and three hematomas (0.7%) during an average 18-month follow-up period. In conclusion, this investigation revealed that closed-suction drainage of the scrotum for approximately 12-24 h following three-piece inflatable penile prosthesis surgery does not result in increased infection rate and is associated with a very low incidence of postoperative hematoma formation, swelling, and ecchymosis.

Hemangiomas in infants and children. An algorithm for intervention

Considerable confusion exists with the diagnosis and management of vascular birthmarks. For this article we reviewed charts for the diagnosis and recommended management of 208 new patients with vascular birthmarks presenting to the Albany Medical Center Vascular Malformation Clinic, Albany, NY, over a 26-month period from October 1995 through December 1997. Based on our patient population, data available, and the current literature, we concluded that an early evaluation and an accurate diagnosis in infants with a vascular birthmark are important. Furthermore, intervention by way of systemic steroids, laser therapy, or surgical debulking is appropriate and safe in a select group of patients presenting with a proliferating hemangioma and in patients with an involuting but disfiguring hemangioma. Also in this article we present an algorithm to assist the clinician with the management of the pediatric patient with a diagnosis of a hemangioma.

Age and responses to the Love Attitudes Scale: consistency in structure, differences in scores

Two separate issues concerning the relation between age and love are addressed in this article. The first issue is concerned with the age generalizability of the factor structure produced by responses to the Love Attitudes Scale. The data presented indicate that the factor structure of responses to the Love Attitudes Scale is highly similar in college-aged and middle-aged participants. The second issue concerns the relation between age and actual scores on the sub-scales of the Love Attitude Scales. The data indicate that age is related to responses on the Mania and Agape sub-scales, particularly for females. Collectively, these data suggest that general structural conceptions of love remain relatively constant into middle-age, but that there is a relation between age and some specific love styles.

Clinical perspectives and current trends of HIV infection in the newborn and child

Pediatric AIDS and HIV infection are issues that have and will continue to receive more and more attention. With the increasing number of children born to HIV-infected women, there are many unanswered questions concerning maternal and child health organizations. This article provides information on the current epidemiology, etiology, and pathophysiology of the HIV infection, methods of diagnosis, and the multisystem clinical manifestations of HIV infection in the infant and child. Prognosis and course of the illness, as well as current research on management, psychosocial, and nursing implications, prevention, and future trends are discussed.

Preliminary X-ray diffraction analysis of crystalline lectins from the seeds and leaves of Sophora japonica

The Japanese Pogada Tree (Sophora japonica) contains at least four distinct lectins distributed among seeds, bark, and leaf tissues of the plant. All of these lectins are N-acetylgalactosamine-specific, have molecular weights of about 130,000, are glycoproteins and possess substantial sequence homology. However, they are products of distinct genes. We have crystallized Sophora lectins from bark, seeds, and two different lectins from leaves. Multiple crystal forms of each variety have been obtained by vapor diffusion with polyethylene glycol 4,000 solutions, and five of the crystal forms have been characterized by X-ray diffraction. The data demonstrates that at least in the case of leaf lectin II, the tetrameric molecule contains at least one exact dyad axis. Several of the crystals appear suitable for high resolution structure analysis.

Spatial strategies in the counting of young children

3--6-year-old children counted 7, 10, and 14 items arranged in columns or in rows. Developmental changes in spatial strategy and the relation of strategy to accuracy were examined. Increases with age in the organization of children's counting sequences were observed as they progressed from (a) a counting sequence based on the proximity of an item to the one previously counted, to (b) a sequence based on the exterior form of the array, to (c) a sequence based on the linear arrangement of items. The column or row arrangement of items did not affect strategy choice, but increasing the number of items caused some children to revert to a less organized count. Fewer errors were associated with more mature strategies at all ages.

A barley lectin that binds free amino sugars. I. Purification and characterization

A lectin was isolated from barley seen which bound the coat glycoprotein of barley stripe mosaic virus (Type strain) and precipitated the virus from solution. Purification of the barley lectin was achieved by fractionation with ammonium sulfate and successive column chromatography on DEAE cellulose and cellulose phosphate. The barley lectin was homogeneous as ascertained by polyacrylamide gel electrophoresis, isoelectric focusing, and from immunochemical tests. No isolectins were detected. The lectin has a molecular weight of 31 000 daltons and is not a glycoprotein. Each virion can accomodate between 200 to 300 molecules of lectin. Barley lectin was shown to be specific for D-glucosamine, D-galactosamine and D-mannosamine with little distinction among the epimeric configurations at carbons 2 and 4. Free amino groups of D-glucosamine and D-galactosamine were detected on the coat glycoprotein of Type strain barley stripe mosaic virus and these sugars appear to serve as receptors for the barley lectin.

Carbohydrate composition of central nervous system synapses. Analysis of isolated synaptic junctional complexes and postsynaptic densities

The composition of specialized structures present at synapses within the central nervous system was elucidated by biochemical analysis of fractions enriched in synaptic junctional complexes and postsynaptic densities. The results indicate that the synaptic junctional complex is primarily protein together with some glycoproteins. The synaptic junctional complex proteins are similar in amino acid composition to synaptic membrane proteins; they are not expecially rich in basic residues, as previously suggested. The major carbohydrates present in the synaptic junctional complex and postsynaptic density glycoproteins are mannose, galactose, and glucosamine, with lesser amounts of fucose, N-acetylneuraminic acid, and galactosamine. Comparison with the synaptic membrane fraction indicates that galactose is more concentrated in the synaptic junctional complex and mannose in the postsynaptic density. Glucose is dramatically enriched in both these fractions. Sucrose binding during isolation may partially account for the glucose enrichment.