Association of Social Determinants of Health With Rapid Response Events: A Retrospective Cohort Trial in a Large Pediatric Academic Hospital System

BACKGROUND

Social determinants of health (SDH) are known to impact hospital and intensive care unit (ICU) outcomes. Little is known about the association between SDH and pediatric rapid response (RR) events and understanding this impact will help guide future interventions aimed to eliminate health disparities in the inpatient setting.

OBJECTIVES

The primary objective of this study is to describe the association between SDH and RR utilization (number of RR events, time to RR event, shift of event and caller). The secondary objective is to determine if SDH can predict hospital length of stay (LOS), ICU transfer, critical deterioration (CD), and mortality.

METHODS

A retrospective cohort study was conducted. We reviewed all RR events from 2016 to 2019 at a large, academic, pediatric hospital system including a level 1 trauma center and two satellite community campuses. All hospitalized patients up to age 25 who had a RR event during their index hospitalization were included. Exposure variables included age, gender, race/ethnicity, language, income, insurance status, chronic disease status, and repeat RR event. The primary outcome variables were hospital LOS, ICU transfer, CD, and mortality. The odds of mortality, CD events and ICU transfer were assessed using unadjusted and multivariable logistic regression. Associations with hospital LOS were assessed with unadjusted and multivariable quantile regression.

RESULTS

Four thousand five hundred and sixty-eight RR events occurred from 3,690 unique admissions and 3301 unique patients, and the cohort was reduced to the index admission. The cohort was largely representative of the population served by the hospital system and varied according to race and ethnicity. There was no variation by race/ethnicity in the number of RR events or the shift in which RR events occurred. Attending physicians initiated RR calls more for event for non-Hispanic patients of mixed or other race (31.6% of events), and fellows and residents were more likely to be the callers for Hispanic patients (29.7% of events, p = 0.002). Families who are non-English speaking are also less likely to activate the RR system (12% of total RR events, p = 0.048). LOS was longest for patients speaking languages other than Spanish or English and CD was more common in patients with government insurance. In adjusted logistic regression, Hispanic patients had 2.5 times the odds of mortality (95% CI: 1.43-4.53, p = 0.002) compared with non-Hispanic white patients.

CONCLUSION

Disparities exist in access to and within the inpatient management of pediatric patients. Our results suggest that interventions to address disparities should focus on Hispanic patients and non-English speaking patients to improve inpatient health equity. More research is needed to understand and address the mortality outcomes in Hispanic children compared to other groups.

Reducing door-to-needle time: treatment delay versus presentation delay

One of the primary goals of the current American College of Cardiology/American Heart Association guidelines for treating patients with AMI is reduction of treatment delay. Delays consist of three phases: time from onset of symptoms to call for help, prehospital care and transportation, and door-to-treatment time. In turn, door-to-treatment time, the delay probably most amenable to change, consists of three distinct intervals: door-to-data, or diagnosis; data-to-decision (which therapy); and decision-to-drug administration. Care should be initiated in the emergency department (ED). Along with ready accessibility of electrocardiograms, interdepartmental protocols that facilitate diagnosis in the ED have been shown to reduce the door-to-data delay. Systems that expedite the exceptional cardiologist consult help speed the time to decision. Along with standing orders for standard care, orally obtained informed consent and availability of the drug in the ED can substantially decrease delay in drug delivery. By reducing unnecessary delays, standardization of protocols for diagnosing and treating patients with AMI in the ED may substantially decrease mortality and morbidity.

Deletion of the alpha(1,3)galactosyl transferase (GGTA1) gene and the prion protein (PrP) gene in sheep

Nuclear transfer offers a cell-based route for producing precise genetic modifications in a range of animal species. Using sheep, we report reproducible targeted gene deletion at two independent loci in fetal fibro-blasts. Vital regions were deleted from the alpha(1,3)galactosyl transferase (GGTA1) gene, which may account for the hyperacute rejection of xenografted organs, and from the prion protein (PrP) gene, which is directly associated with spongiform encephalopathies in humans and animals. Reconstructed embryos were prepared using cultures of targeted or nontargeted donor cells. Eight pregnancies were maintained to term and four PrP-/+ lambs were born. Although three of these perished soon after birth, one survived for 12 days. These data show that lambs carrying targeted gene deletions can be generated by nuclear transfer.

Initial experience with laparoscopic ultrasound-guided radiofrequency thermal ablation of hepatic tumours

BACKGROUND AND STUDY AIMS

Radiofrequency (RF) thermal ablation has been applied almost exclusively through the percutaneous approach under radiological/external ultrasound guidance. We have embarked on a programme of laparoscopic ultrasound-guided RF ablation of hepatic tumours in view of the potential advantages of this approach, i. e. reduced heat sink effect, greater precision and improved assessment of the thermal ablative zone.

PATIENTS AND METHODS

RF thermal ablation using the Zomed International generator and multielectrode probes in two patients with hepatoma arising on a background of cirrhosis and in eight patients with multiple deposits from primary colorectal cancer.

RESULTS

Total ablation was performed in two patients with hepatoma and 7/8 patients with secondary deposits. Total ablation with a minimum of 0.5-cm margin was achieved in 32 lesions. No complications were encountered postoperatively and all patients were discharged within 2 days of the intervention. One patient in whom thermal ablation was not completed has since died of progressive disease, eight appear to be free of tumour (follow-up 6-20 months) but one patient has developed further secondary hepatic deposits.

CONCLUSIONS

The initial experience with laparoscopic ultrasound-guided RF ablation of hepatic tumours indicates its safety and therapeutic potential in patients with inoperable hepatic tumours.

Effect of muscle injection site and drug temperature on pre-anaesthetic sedation in pigs

The responses of 83 Meishan gilts given azaperone (1.0 mg/kg) and ketamine (5 mg/kg) intramuscularly at one of four sites: the cervical muscles (20); the triceps muscle (m triceps brachii) (20); the middle gluteal muscle (m gluteus medius) (22); and the fascia lata muscle (m fascia lata) (21) were recorded. There were more reactions to the injection into the fascia lata muscle than to injections into the middle gluteal muscle and the triceps muscle (P = 0.024) and fewest after injections into the cervical muscles (P = 0.013). The injection site did not influence the time from injection to recumbency but there was least variability with the fascia lata muscle. The degree of sedation achieved, and the response to venous cannulation were similar in all four groups. There were no long-term complications (lameness or abscess formation) associated with the injections at any of the sites. In a second study with 68 pigs the same drug mixture was injected into the triceps muscle at either 6 to 8 degrees C (23), 19 to 22 degrees C (23) or 38.5 to 40.5 degrees C (22). There was no significant difference (P = 0.078) between the numbers of responses to the injections at each temperature. Mean time to recumbency was shortest with the injections at the highest temperature although the differences were not statistically significant (P = 0.498). The degree of sedation achieved, the response to venous cannulation and the incidence of complications were similar in all three groups.

Effects of North Carolina's mandatory safety belt law on children

OBJECTIVES

To assess the effect of the North Carolina law mandating that all front seat passengers use a safety belt on children 4 through 15 years of age.

METHODS

North Carolina collision reports, completed by local police or the state highway patrol for crashes with greater than $500 worth of damage, were analyzed using time series analysis on the monthly percentage of deaths and serious injuries between January of 1980 and February of 1994.

RESULTS

Following the 1985 implementation of the law, children 4 to 15 years of age experienced a 42% decline in deaths and serious injuries.

CONCLUSIONS

The mandatory safety belt law in North Carolina has been associated with a decline in deaths and serious injuries. Additional research in needed to assess the seat belt behaviors of this age group as well as the specific effects of seat belt use using outcome measures more precise than those available in police crash reports.

An epidemiologic study of prn/stat medication use in a state psychiatric hospital

The prevalence of prn/stat psychotropic medication administration and the characteristics and concomitants of high use of these medications were examined via a retrospective medical record review in a 973-bed state hospital. While 22.9% of the total hospital population received at least 1 prn/stat dose during the study month, 27 patients (2.8% of the total population) received 44.4% of the prn/stat doses, averaging 9.7 doses per patient. Examination of high-prn/stat use patients whose disruptive behavior and prn/stat use was "intermittent" throughout the month (N = 16) vs those who exhibited these characteristic for only a "discrete period" with resolution (N = 11) suggested that the prescription of antipsychotic drugs as prn/stat doses as well as increases in or institution of these medications was significantly associated with the latter group's resolution of disruptive behavior. The findings suggest the need for clinical protocols as guides for clinicians in the establishment of effective pharmacotherapy for patients with agitated, threatening behavior, including the use of plasma levels to ensure adequate dosage of psychotropic medication.

A case-control study of rapid readmission in a state hospital population

A case-control comparison of clinical and service system characteristics among chronic psychiatric patients with rapid readmission (within 90 days of discharge), patients with readmission after more than 90 days of community tenure, and nonreadmitted patients revealed several clinical variables (e.g., medication noncompliance, substance abuse, and disruptive behavior) to be associated with readmission regardless of community tenure. In contrast, two service system variables (discharge to a structured outpatient treatment program and adequacy of discharge planning) were more highly associated with rapid readmission than the other conditions, while availability of case management had no association with readmission, rapid or otherwise.

A strategy for adaptive staffing of hospitals under varying environmental conditions

With many hospitals facing periods of retrenchment or considerable uncertainty in workload and reimbursement policy, an adaptive management response seems to be required. A model is presented for the development and implementation of a system of flexible resource management that is useful for health service managers.

Pneumonia and psychotropic drug use in elderly psychiatric patients

A study of the use of psychotropic drugs among 30 elderly psychiatric patients with pneumonia (15 of whom died), in comparison to the general elderly population of the hospital, revealed a negative association between the use of psychotropic agents and the development of pneumonia. The factors of age, sex, pre-existing illness, and organism virulence/patient resistance were all associated with death from pneumonia. However, the present findings do not support the hypothesis that psychotropic drugs are implicated in pneumonia deaths among elderly psychiatric patients.

Application of glass capillary columns to monitor petroleum-type hydrocarbons in marine sediments

High resolution glass capillary columns coated with SE 52 liquid phase were used to resolve the indigenous hydrocarbons extracted from sediment samples collected from three outer continental shelf areas. The extracts were than spiked with small amounts of aliphatic or aromatic components isolated from a Louisiana crude oil and rechromatographed. The resolution was sufficient to separate almost all the isoprenoid, branched and cyclic alkanes associated with petroleum. Additionally, many of the key petroleum aromatics could also be resolved from naturally occurring organics. Such chromatographic procedures will aid in distinguishing between indigenous hydrocarbons of contemporary origin and those known to be associated with fossil hydrocarbon pollution of marine sediments.