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Study: Don’t separate NAS infants from moms
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
AT PHM 2017
Key clinical point:
Major finding: Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from, in one study, a mean of almost $45,000 per NAS infant stay to just over $10,000.
Data source: A meta-analysis of six studies.
Disclosures: The investigators had no relevant financial disclosures.
How to reduce NICU transfers for asymptomatic hypoglycemia
NASHVILLE, TENN. – At the University of North Carolina at Chapel Hill, many infants who would previously have been transferred to the NICU for asymptomatic hypoglycemia now are staying with their moms, thanks to a new protocol that holds off on blood glucose testing until infants are fed for the first time and glucose homeostasis can begin.
Not too long ago, the university realized it had a problem that’s probably familiar to other institutions: Its system to monitor newborns at risk for hypoglycemia – those born to diabetic mothers, or who are small or large for gestational age – put too many infants with asymptomatic hypoglycemia into the NICU when they didn’t really need to be there.
Nurse practitioners “were tired of transferring babies they felt were responsive to feeding and did not actually require NICU care,” and “a growing number of families were unhappy with being separated from infants that were well-appearing and feeding well at a time when moms were trying to establish breast feeding and bonding. There was frustration with our protocol,” which “seemed rigid and outdated,” said Ashley Sutton, MD, a pediatric hospitalist at the university.
To fix the problem, Dr. Sutton and others on a multidisciplinary team implemented the American Academy of Pediatrics’ 2011 guidelines for monitoring glucose homeostasis in late-preterm and term newborns at-risk for hypoglycemia, with an additional mandate to initiate immediate, continual skin-to-skin contact at delivery (Pediatrics. 2011 Mar;127[3]:575-9).
Under the new system, children are fed with either their mom’s or a donor’s breast milk within an hour of birth, and the initial glucose check comes at 90 minutes; infants are transferred if blood glucose remains below 25 mg/dL after the second feeding. After 4 hours of life, glucose levels below 35 mg/dL trigger an evaluation for symptoms, not necessarily an automatic NICU transfer.
Labor and delivery nurses also are empowered “to immediately feed the baby no matter what number [they are] seeing,” Dr. Sutton said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The efforts have made a difference. The transfer rate for at-risk infants has fallen from 17% to 3%, and skin-to-skin contact is initiated within the first hour of life in 64%, up from 45%. Feeding of at-risk infants within the first hour has increased from 43% to 61%, and the first glucose check comes at an average of 97 minutes. The number of unnecessary NICU transfers of at-risk infants has fallen sharply.
Meanwhile, there’s been no increase in sepsis evaluations, adverse events, readmissions, and the rates of symptomatic hypoglycemia.
Dr. Sutton and her colleagues had no industry disclosures. The work was funded by the National Institutes of Health.
NASHVILLE, TENN. – At the University of North Carolina at Chapel Hill, many infants who would previously have been transferred to the NICU for asymptomatic hypoglycemia now are staying with their moms, thanks to a new protocol that holds off on blood glucose testing until infants are fed for the first time and glucose homeostasis can begin.
Not too long ago, the university realized it had a problem that’s probably familiar to other institutions: Its system to monitor newborns at risk for hypoglycemia – those born to diabetic mothers, or who are small or large for gestational age – put too many infants with asymptomatic hypoglycemia into the NICU when they didn’t really need to be there.
Nurse practitioners “were tired of transferring babies they felt were responsive to feeding and did not actually require NICU care,” and “a growing number of families were unhappy with being separated from infants that were well-appearing and feeding well at a time when moms were trying to establish breast feeding and bonding. There was frustration with our protocol,” which “seemed rigid and outdated,” said Ashley Sutton, MD, a pediatric hospitalist at the university.
To fix the problem, Dr. Sutton and others on a multidisciplinary team implemented the American Academy of Pediatrics’ 2011 guidelines for monitoring glucose homeostasis in late-preterm and term newborns at-risk for hypoglycemia, with an additional mandate to initiate immediate, continual skin-to-skin contact at delivery (Pediatrics. 2011 Mar;127[3]:575-9).
Under the new system, children are fed with either their mom’s or a donor’s breast milk within an hour of birth, and the initial glucose check comes at 90 minutes; infants are transferred if blood glucose remains below 25 mg/dL after the second feeding. After 4 hours of life, glucose levels below 35 mg/dL trigger an evaluation for symptoms, not necessarily an automatic NICU transfer.
Labor and delivery nurses also are empowered “to immediately feed the baby no matter what number [they are] seeing,” Dr. Sutton said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The efforts have made a difference. The transfer rate for at-risk infants has fallen from 17% to 3%, and skin-to-skin contact is initiated within the first hour of life in 64%, up from 45%. Feeding of at-risk infants within the first hour has increased from 43% to 61%, and the first glucose check comes at an average of 97 minutes. The number of unnecessary NICU transfers of at-risk infants has fallen sharply.
Meanwhile, there’s been no increase in sepsis evaluations, adverse events, readmissions, and the rates of symptomatic hypoglycemia.
Dr. Sutton and her colleagues had no industry disclosures. The work was funded by the National Institutes of Health.
NASHVILLE, TENN. – At the University of North Carolina at Chapel Hill, many infants who would previously have been transferred to the NICU for asymptomatic hypoglycemia now are staying with their moms, thanks to a new protocol that holds off on blood glucose testing until infants are fed for the first time and glucose homeostasis can begin.
Not too long ago, the university realized it had a problem that’s probably familiar to other institutions: Its system to monitor newborns at risk for hypoglycemia – those born to diabetic mothers, or who are small or large for gestational age – put too many infants with asymptomatic hypoglycemia into the NICU when they didn’t really need to be there.
Nurse practitioners “were tired of transferring babies they felt were responsive to feeding and did not actually require NICU care,” and “a growing number of families were unhappy with being separated from infants that were well-appearing and feeding well at a time when moms were trying to establish breast feeding and bonding. There was frustration with our protocol,” which “seemed rigid and outdated,” said Ashley Sutton, MD, a pediatric hospitalist at the university.
To fix the problem, Dr. Sutton and others on a multidisciplinary team implemented the American Academy of Pediatrics’ 2011 guidelines for monitoring glucose homeostasis in late-preterm and term newborns at-risk for hypoglycemia, with an additional mandate to initiate immediate, continual skin-to-skin contact at delivery (Pediatrics. 2011 Mar;127[3]:575-9).
Under the new system, children are fed with either their mom’s or a donor’s breast milk within an hour of birth, and the initial glucose check comes at 90 minutes; infants are transferred if blood glucose remains below 25 mg/dL after the second feeding. After 4 hours of life, glucose levels below 35 mg/dL trigger an evaluation for symptoms, not necessarily an automatic NICU transfer.
Labor and delivery nurses also are empowered “to immediately feed the baby no matter what number [they are] seeing,” Dr. Sutton said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The efforts have made a difference. The transfer rate for at-risk infants has fallen from 17% to 3%, and skin-to-skin contact is initiated within the first hour of life in 64%, up from 45%. Feeding of at-risk infants within the first hour has increased from 43% to 61%, and the first glucose check comes at an average of 97 minutes. The number of unnecessary NICU transfers of at-risk infants has fallen sharply.
Meanwhile, there’s been no increase in sepsis evaluations, adverse events, readmissions, and the rates of symptomatic hypoglycemia.
Dr. Sutton and her colleagues had no industry disclosures. The work was funded by the National Institutes of Health.
AT PHM 2017
Key clinical point:
Major finding: After making that and other changes, the transfer rate for at-risk infants at a major academic center fell from 17% to 3%, without an increase in rates of symptomatic hypoglycemia and adverse events.
Data source: Quality improvement project at the University of North Carolina at Chapel Hill.
Disclosures: The investigators had no financial disclosures. The work was funded by the National Institutes of Health.
Axillary thermometry is the best choice for newborns
NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.
The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.
Lead investigator Ketan Nadkarni, MD, a 3rd-year pediatrics resident, and his colleagues wanted to compare the three methods head-to-head to make sure axillary thermometers were okay to use in the nursery, and to see if it really was necessary to tell parents to use rectal thermometers; many are reluctant to use them. Plus, “there’s been a lot of controversy” in pediatrics “over the best way to measure temperature,” Dr. Nadkarni said at the Pediatric Hospital Medicine annual meeting.
“With our data, we think axillary is what we should continue to use in the newborn nursery,” he said. Some attending physicians still are hesitant to recommend axillary thermometers to new parents, but “all of the nurses are aware of” the study findings “and a lot of the residents are, too, so I think we are starting to move” in that direction.
The study had some unexpected findings as well: “The biggest surprise was how wide the distribution of rectal temperatures was. The distribution” around the mean “was way larger than we had thought, so [rectal thermometry was] not very reliable at all. Our study surprisingly exhibited suboptimal performance in terms of reliability,” for rectal thermometry, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Specifically, the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F. The second rectal temperature in the study sometimes varied a half a degree or more from the first taken shortly before, in the same infant.
The average distance of an axillary temperature from the axillary mean of 98.32º F was 0.32º F; for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Another surprise was that temporal thermometry overestimated temperature by an average of about a quarter of a degree, compared with rectal readings. Even small overestimates could lead to unnecessary sepsis work-ups; “the last thing we want is to hospitalize these kids when they don’t need to be,” Dr. Nadkarni said.
The mean axillary and rectal temperatures, meanwhile, were only 0.02º F apart, which was not statistically significant. “Axillary was absolutely interchangeable with rectal in terms of accuracy,” he said.
The children were born at 37 weeks’ gestation or later, and were excluded if they had a temperature of 100.4º F or higher by any method. Rectal and axillary temperatures were taken with a Welch Allyn SureTemp Plus 690. Temple temperatures were taken with an Exergen TAT-2000c.
The investigators plan to run a similar trial in the ED with children up to 3 months old.
There was no external funding for the work, and Dr. Nadkarni had no relevant financial disclosures.
NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.
The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.
Lead investigator Ketan Nadkarni, MD, a 3rd-year pediatrics resident, and his colleagues wanted to compare the three methods head-to-head to make sure axillary thermometers were okay to use in the nursery, and to see if it really was necessary to tell parents to use rectal thermometers; many are reluctant to use them. Plus, “there’s been a lot of controversy” in pediatrics “over the best way to measure temperature,” Dr. Nadkarni said at the Pediatric Hospital Medicine annual meeting.
“With our data, we think axillary is what we should continue to use in the newborn nursery,” he said. Some attending physicians still are hesitant to recommend axillary thermometers to new parents, but “all of the nurses are aware of” the study findings “and a lot of the residents are, too, so I think we are starting to move” in that direction.
The study had some unexpected findings as well: “The biggest surprise was how wide the distribution of rectal temperatures was. The distribution” around the mean “was way larger than we had thought, so [rectal thermometry was] not very reliable at all. Our study surprisingly exhibited suboptimal performance in terms of reliability,” for rectal thermometry, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Specifically, the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F. The second rectal temperature in the study sometimes varied a half a degree or more from the first taken shortly before, in the same infant.
The average distance of an axillary temperature from the axillary mean of 98.32º F was 0.32º F; for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Another surprise was that temporal thermometry overestimated temperature by an average of about a quarter of a degree, compared with rectal readings. Even small overestimates could lead to unnecessary sepsis work-ups; “the last thing we want is to hospitalize these kids when they don’t need to be,” Dr. Nadkarni said.
The mean axillary and rectal temperatures, meanwhile, were only 0.02º F apart, which was not statistically significant. “Axillary was absolutely interchangeable with rectal in terms of accuracy,” he said.
The children were born at 37 weeks’ gestation or later, and were excluded if they had a temperature of 100.4º F or higher by any method. Rectal and axillary temperatures were taken with a Welch Allyn SureTemp Plus 690. Temple temperatures were taken with an Exergen TAT-2000c.
The investigators plan to run a similar trial in the ED with children up to 3 months old.
There was no external funding for the work, and Dr. Nadkarni had no relevant financial disclosures.
NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.
The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.
Lead investigator Ketan Nadkarni, MD, a 3rd-year pediatrics resident, and his colleagues wanted to compare the three methods head-to-head to make sure axillary thermometers were okay to use in the nursery, and to see if it really was necessary to tell parents to use rectal thermometers; many are reluctant to use them. Plus, “there’s been a lot of controversy” in pediatrics “over the best way to measure temperature,” Dr. Nadkarni said at the Pediatric Hospital Medicine annual meeting.
“With our data, we think axillary is what we should continue to use in the newborn nursery,” he said. Some attending physicians still are hesitant to recommend axillary thermometers to new parents, but “all of the nurses are aware of” the study findings “and a lot of the residents are, too, so I think we are starting to move” in that direction.
The study had some unexpected findings as well: “The biggest surprise was how wide the distribution of rectal temperatures was. The distribution” around the mean “was way larger than we had thought, so [rectal thermometry was] not very reliable at all. Our study surprisingly exhibited suboptimal performance in terms of reliability,” for rectal thermometry, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Specifically, the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F. The second rectal temperature in the study sometimes varied a half a degree or more from the first taken shortly before, in the same infant.
The average distance of an axillary temperature from the axillary mean of 98.32º F was 0.32º F; for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Another surprise was that temporal thermometry overestimated temperature by an average of about a quarter of a degree, compared with rectal readings. Even small overestimates could lead to unnecessary sepsis work-ups; “the last thing we want is to hospitalize these kids when they don’t need to be,” Dr. Nadkarni said.
The mean axillary and rectal temperatures, meanwhile, were only 0.02º F apart, which was not statistically significant. “Axillary was absolutely interchangeable with rectal in terms of accuracy,” he said.
The children were born at 37 weeks’ gestation or later, and were excluded if they had a temperature of 100.4º F or higher by any method. Rectal and axillary temperatures were taken with a Welch Allyn SureTemp Plus 690. Temple temperatures were taken with an Exergen TAT-2000c.
The investigators plan to run a similar trial in the ED with children up to 3 months old.
There was no external funding for the work, and Dr. Nadkarni had no relevant financial disclosures.
AT PHM 2017
Key clinical point:
Major finding: The average distance of an axillary temperature from the axillary mean of 98.32º F was only 0.32º F, while the average distance of any given rectal measurement from the mean rectal temperature of 98.3º F was 0.45º F, and for temporal thermometry it was 0.34º F from a mean of 98.55º F.
Data source: Head-to-head thermometry study in more than 200 infants aged 12-72 hours.
Disclosures: There was no outside funding, and Dr. Nadkarni had no relevant financial disclosures.
When families participate in rounds, errors decrease
NASHVILLE, TENN. – When families are actively included in pediatric hospital rounds, preventable adverse events drop 38% and families report better hospital experiences, with no negative impact on rounds duration or teaching, according to a prospective investigation on inpatient pediatric units of seven North American hospitals.
“We always talk about how parents know their children better than anyone else; empowering the family to know what we are looking for can have downstream safety implications,” she said. In the study, families often caught problems before medical staff, such as IV infiltrations. They also reported delays in diagnoses and conflicting information, among other things, Dr. Khan explained at the Pediatric Hospital Medicine meeting.
There’s not much data on family-centered rounds in pediatric medicine, so Dr. Khan and her team decided to investigate. They modified the I-PASS resident handoff model (illness severity; patient summary; action list; situation awareness and contingency planning; and synthesis by receiver) to be more family friendly.
Families were given a short form before rounds that asked if their child was better, worse, or about the same as the day before, and what questions and items they wanted to address. There was also space for them to take notes during the presentation about what had changed overnight, what still needed to be done, and what to look out for.
Families were given the opportunity to speak first during rounds, and medical staff used plain language: “has a fever” instead of “febrile,” for instance. At the end of the presentation, families were asked to read back their take-aways.
The investigators compared baseline data from the 3 months before implementation with data for the 3 months afterward. The study included more than 1,500 patients and more than 300 rounds in both the pre- and postimplementation arms. The children were general inpatients; surgery and ICU patients were excluded.
Harmful errors/preventable AEs dropped from 20.7/1,000 patients days to 12.9/1,000 after implementation, a 38% reduction (P = .01). There was also a reduction in overall AEs from 34 to 18.5/1,000 patient-days (P = .002).
Compared with baseline data, after implementation, families were more likely to report that they understood the medical plan and what was said on rounds. They also were more likely to report that nurses had addressed their concerns and made them feel like an important member of the team.
Direct observation of pre- and postimplementation rounds showed that family and nursing engagement improved and families more often got written updates. There were no statistically significant differences in rounds duration or decreases in teaching.
“Congratulations. This is very impressive work, and also the right thing to do,” an audience member said after Dr. Khan’s presentation at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The work was funded by the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality. Dr. Khan had no disclosures.
NASHVILLE, TENN. – When families are actively included in pediatric hospital rounds, preventable adverse events drop 38% and families report better hospital experiences, with no negative impact on rounds duration or teaching, according to a prospective investigation on inpatient pediatric units of seven North American hospitals.
“We always talk about how parents know their children better than anyone else; empowering the family to know what we are looking for can have downstream safety implications,” she said. In the study, families often caught problems before medical staff, such as IV infiltrations. They also reported delays in diagnoses and conflicting information, among other things, Dr. Khan explained at the Pediatric Hospital Medicine meeting.
There’s not much data on family-centered rounds in pediatric medicine, so Dr. Khan and her team decided to investigate. They modified the I-PASS resident handoff model (illness severity; patient summary; action list; situation awareness and contingency planning; and synthesis by receiver) to be more family friendly.
Families were given a short form before rounds that asked if their child was better, worse, or about the same as the day before, and what questions and items they wanted to address. There was also space for them to take notes during the presentation about what had changed overnight, what still needed to be done, and what to look out for.
Families were given the opportunity to speak first during rounds, and medical staff used plain language: “has a fever” instead of “febrile,” for instance. At the end of the presentation, families were asked to read back their take-aways.
The investigators compared baseline data from the 3 months before implementation with data for the 3 months afterward. The study included more than 1,500 patients and more than 300 rounds in both the pre- and postimplementation arms. The children were general inpatients; surgery and ICU patients were excluded.
Harmful errors/preventable AEs dropped from 20.7/1,000 patients days to 12.9/1,000 after implementation, a 38% reduction (P = .01). There was also a reduction in overall AEs from 34 to 18.5/1,000 patient-days (P = .002).
Compared with baseline data, after implementation, families were more likely to report that they understood the medical plan and what was said on rounds. They also were more likely to report that nurses had addressed their concerns and made them feel like an important member of the team.
Direct observation of pre- and postimplementation rounds showed that family and nursing engagement improved and families more often got written updates. There were no statistically significant differences in rounds duration or decreases in teaching.
“Congratulations. This is very impressive work, and also the right thing to do,” an audience member said after Dr. Khan’s presentation at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The work was funded by the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality. Dr. Khan had no disclosures.
NASHVILLE, TENN. – When families are actively included in pediatric hospital rounds, preventable adverse events drop 38% and families report better hospital experiences, with no negative impact on rounds duration or teaching, according to a prospective investigation on inpatient pediatric units of seven North American hospitals.
“We always talk about how parents know their children better than anyone else; empowering the family to know what we are looking for can have downstream safety implications,” she said. In the study, families often caught problems before medical staff, such as IV infiltrations. They also reported delays in diagnoses and conflicting information, among other things, Dr. Khan explained at the Pediatric Hospital Medicine meeting.
There’s not much data on family-centered rounds in pediatric medicine, so Dr. Khan and her team decided to investigate. They modified the I-PASS resident handoff model (illness severity; patient summary; action list; situation awareness and contingency planning; and synthesis by receiver) to be more family friendly.
Families were given a short form before rounds that asked if their child was better, worse, or about the same as the day before, and what questions and items they wanted to address. There was also space for them to take notes during the presentation about what had changed overnight, what still needed to be done, and what to look out for.
Families were given the opportunity to speak first during rounds, and medical staff used plain language: “has a fever” instead of “febrile,” for instance. At the end of the presentation, families were asked to read back their take-aways.
The investigators compared baseline data from the 3 months before implementation with data for the 3 months afterward. The study included more than 1,500 patients and more than 300 rounds in both the pre- and postimplementation arms. The children were general inpatients; surgery and ICU patients were excluded.
Harmful errors/preventable AEs dropped from 20.7/1,000 patients days to 12.9/1,000 after implementation, a 38% reduction (P = .01). There was also a reduction in overall AEs from 34 to 18.5/1,000 patient-days (P = .002).
Compared with baseline data, after implementation, families were more likely to report that they understood the medical plan and what was said on rounds. They also were more likely to report that nurses had addressed their concerns and made them feel like an important member of the team.
Direct observation of pre- and postimplementation rounds showed that family and nursing engagement improved and families more often got written updates. There were no statistically significant differences in rounds duration or decreases in teaching.
“Congratulations. This is very impressive work, and also the right thing to do,” an audience member said after Dr. Khan’s presentation at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The work was funded by the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality. Dr. Khan had no disclosures.
AT PHM 2017
Key clinical point:
Major finding: Harmful errors/preventable AEs dropped from 20.7/1,000 patients days to 12.9 after implementation of a program to engage families in pediatric rounds, a 38% reduction (P = .01).
Data source: More than 600 pediatric inpatient rounds at seven North American hospitals.
Disclosures: The work was funded by the Patient-Centered Outcomes Research Institute and the Agency for Healthcare Research and Quality. The lead investigator had no disclosures.
High-flow nasal cannula safe outside of pediatric ICU, but may up length of stay
NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.
Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.
The increase correlated with a drop in intubation for acute bronchiolitis from 14% of children in 2010-2011 to just 2% in 2015-2016. The only HFNC adverse events were minor air leaks in two children.
As HFNC became more common, however, the Dallas team found that length of stay for acute bronchiolitis increased from 1.8 days in 2011-2012 to 2.4 days in 2015-2016, perhaps because the use of HFNC gives providers the impression that children are sicker than they actually are.
To counter the problem, lead investigator Vineeta Mittal, MD, associate professor of pediatrics, and her colleagues created an HFNC weaning protocol that gradually steps down treatment based on blood oxygen saturation levels and breathing effort, leading ultimately to a room-air challenge. It helped; the mean length of stay as of November 2016 was 1.7 days.
There’s been pushback in some places about giving HFNC on the floor: Intensivists sometimes consider it a form of ventilation that should be administered in the PICU. At levels up to 6 L/min and 50% oxygen, though, HFNC is “safe to give on the floor, because there’s no pneumothorax risk,” Dr. Mittal explained. HFNC “is not a ventilator; it’s an effective form of noninvasive respiratory support in children with moderate to severe respiratory distress from bronchiolitis.”
At Southwestern, “we are managing 80% of cases on the floor” with the help of HFNC, Dr. Mittal said at Pediatric Hospital Medicine.
At least for now, children at Southwestern go to the PICU if they need higher flow rates, but Dr. Mittal said it’s not clear if that’s necessary. “We said [6 L/min] is safe,” but maybe “we could even use 8 L/min or even 12 L/min” – the maximum delivered in the PICU over the study period – “because we know it’s safe,” she said. In addition, keeping kids on the floor also saves money, she noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Dr. Mittal is concerned HFNC might be overused. “We have gotten so used to this machine that the moment we see distress, we put the kid on high flow,” rather than observing them for a bit to see if they recover on their own. More data are needed to determine when HFNC should be initiated, and when to pull the plug on HFNC and intubate, she said.
Dr. Mittal had no disclosures.
NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.
Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.
The increase correlated with a drop in intubation for acute bronchiolitis from 14% of children in 2010-2011 to just 2% in 2015-2016. The only HFNC adverse events were minor air leaks in two children.
As HFNC became more common, however, the Dallas team found that length of stay for acute bronchiolitis increased from 1.8 days in 2011-2012 to 2.4 days in 2015-2016, perhaps because the use of HFNC gives providers the impression that children are sicker than they actually are.
To counter the problem, lead investigator Vineeta Mittal, MD, associate professor of pediatrics, and her colleagues created an HFNC weaning protocol that gradually steps down treatment based on blood oxygen saturation levels and breathing effort, leading ultimately to a room-air challenge. It helped; the mean length of stay as of November 2016 was 1.7 days.
There’s been pushback in some places about giving HFNC on the floor: Intensivists sometimes consider it a form of ventilation that should be administered in the PICU. At levels up to 6 L/min and 50% oxygen, though, HFNC is “safe to give on the floor, because there’s no pneumothorax risk,” Dr. Mittal explained. HFNC “is not a ventilator; it’s an effective form of noninvasive respiratory support in children with moderate to severe respiratory distress from bronchiolitis.”
At Southwestern, “we are managing 80% of cases on the floor” with the help of HFNC, Dr. Mittal said at Pediatric Hospital Medicine.
At least for now, children at Southwestern go to the PICU if they need higher flow rates, but Dr. Mittal said it’s not clear if that’s necessary. “We said [6 L/min] is safe,” but maybe “we could even use 8 L/min or even 12 L/min” – the maximum delivered in the PICU over the study period – “because we know it’s safe,” she said. In addition, keeping kids on the floor also saves money, she noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Dr. Mittal is concerned HFNC might be overused. “We have gotten so used to this machine that the moment we see distress, we put the kid on high flow,” rather than observing them for a bit to see if they recover on their own. More data are needed to determine when HFNC should be initiated, and when to pull the plug on HFNC and intubate, she said.
Dr. Mittal had no disclosures.
NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.
Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.
The increase correlated with a drop in intubation for acute bronchiolitis from 14% of children in 2010-2011 to just 2% in 2015-2016. The only HFNC adverse events were minor air leaks in two children.
As HFNC became more common, however, the Dallas team found that length of stay for acute bronchiolitis increased from 1.8 days in 2011-2012 to 2.4 days in 2015-2016, perhaps because the use of HFNC gives providers the impression that children are sicker than they actually are.
To counter the problem, lead investigator Vineeta Mittal, MD, associate professor of pediatrics, and her colleagues created an HFNC weaning protocol that gradually steps down treatment based on blood oxygen saturation levels and breathing effort, leading ultimately to a room-air challenge. It helped; the mean length of stay as of November 2016 was 1.7 days.
There’s been pushback in some places about giving HFNC on the floor: Intensivists sometimes consider it a form of ventilation that should be administered in the PICU. At levels up to 6 L/min and 50% oxygen, though, HFNC is “safe to give on the floor, because there’s no pneumothorax risk,” Dr. Mittal explained. HFNC “is not a ventilator; it’s an effective form of noninvasive respiratory support in children with moderate to severe respiratory distress from bronchiolitis.”
At Southwestern, “we are managing 80% of cases on the floor” with the help of HFNC, Dr. Mittal said at Pediatric Hospital Medicine.
At least for now, children at Southwestern go to the PICU if they need higher flow rates, but Dr. Mittal said it’s not clear if that’s necessary. “We said [6 L/min] is safe,” but maybe “we could even use 8 L/min or even 12 L/min” – the maximum delivered in the PICU over the study period – “because we know it’s safe,” she said. In addition, keeping kids on the floor also saves money, she noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Dr. Mittal is concerned HFNC might be overused. “We have gotten so used to this machine that the moment we see distress, we put the kid on high flow,” rather than observing them for a bit to see if they recover on their own. More data are needed to determine when HFNC should be initiated, and when to pull the plug on HFNC and intubate, she said.
Dr. Mittal had no disclosures.
AT PHM 2017
Key clinical point:
Major finding: The increased use of HFNC corresponded with an increase in length of stay for acute bronchiolitis, from 1.8 days in the 2011-2012 season to 2.4 days in the 2015-2016 season.
Data source: A single-center review of almost 7,000 acute bronchiolitis cases.
Disclosures: The lead investigator had no disclosures.
PHM17 session summary: Demonstrating teaching excellence with an educator’s portfolio
NASHVILLE, TENN. – Development of a medical educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process, according to an expert panel at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Promote yourself: Demonstrating teaching excellence with an educator’s portfolio
Presenters
Michael Ryan, MD, MEHP; Ashlie Tseng, MD; Jocelyn Schiller, MD; Rebecca Tenney-Soeiro, MD, MEd; Michele Long, MD; Corki Lehmann, MD, MEd; Amy Fleming, MD; and H. Barrett Fromme, MD, MHPE
Session summary
Development of an educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process. Each institution has its own specific requirements for the educator’s portfolio, but there are several general themes that should be considered for inclusion:
1. Develop an educational philosophy. This is a personal statement that frames the rest of the portfolio and describes how this philosophy is used by the educator in his/her approach to education.
2. Teaching. Include teaching activities that are both formal (i.e. lectures) and sessions that encourage more active participation (i.e. small group discussions). This can be accomplished by generating a teaching activities report, which helps to categorize these activities. This will not only demonstrate the volume of teaching experience, but also help to demonstrate the diversity of an educator’s teaching activities. In this section, an educator also should include teaching awards received.
3. Learner evaluations. A qualitative summary of comments will provide a narrative of the educator’s teaching skills. This section also may include summaries of annual reviews of teaching.
4. Curriculum development. Demonstrate the educator’s active engagement in the development of a novel curriculum or the improvement of a pre-existing curriculum and the successful outcomes of those improvements.
5. Mentoring and advising. Generating a list of advisees and highlighting their accomplishments reflects on the ability of the educator to guide and promote success in his/her learners.
6. Educational leadership and administration. This is a description of the past and present leadership roles that the educator has held, including courses or clerkships directed. This should allow the educator the opportunity to provide a narrative description of his/her involvement beyond what is typically stated on the curriculum vitae.
7. Professional development. The educator should develop a list of activities, including formal degree programs, certificate programs, and educational workshops, in which he/she has participated as a learner and have enhanced his/her skills as an educator.
8. Products of educational scholarship. Generate a list of education-related peer-reviewed publications authored, other educational products (such as a syllabus or curriculum) developed, and educational workshops that the educator was invited to give.
For clinician educators interested in developing an educator’s portfolio, there are several resources available, including the Academic Pediatric Association’s website and several MedEdPORTAL publications.
Key takeaways for Pediatric HM
• While each institution has its own specific requirements, there are general themes to consider including in an educator’s portfolio.
• Resources such as the Academic Pediatric Association’s website can help guide an educator in the development of his/her portfolio.
Dr. Player is a pediatric hospitalist at Children’s Hospital of Wisconsin and assistant professor at the Medical College of Wisconsin, Milwaukee.
NASHVILLE, TENN. – Development of a medical educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process, according to an expert panel at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Promote yourself: Demonstrating teaching excellence with an educator’s portfolio
Presenters
Michael Ryan, MD, MEHP; Ashlie Tseng, MD; Jocelyn Schiller, MD; Rebecca Tenney-Soeiro, MD, MEd; Michele Long, MD; Corki Lehmann, MD, MEd; Amy Fleming, MD; and H. Barrett Fromme, MD, MHPE
Session summary
Development of an educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process. Each institution has its own specific requirements for the educator’s portfolio, but there are several general themes that should be considered for inclusion:
1. Develop an educational philosophy. This is a personal statement that frames the rest of the portfolio and describes how this philosophy is used by the educator in his/her approach to education.
2. Teaching. Include teaching activities that are both formal (i.e. lectures) and sessions that encourage more active participation (i.e. small group discussions). This can be accomplished by generating a teaching activities report, which helps to categorize these activities. This will not only demonstrate the volume of teaching experience, but also help to demonstrate the diversity of an educator’s teaching activities. In this section, an educator also should include teaching awards received.
3. Learner evaluations. A qualitative summary of comments will provide a narrative of the educator’s teaching skills. This section also may include summaries of annual reviews of teaching.
4. Curriculum development. Demonstrate the educator’s active engagement in the development of a novel curriculum or the improvement of a pre-existing curriculum and the successful outcomes of those improvements.
5. Mentoring and advising. Generating a list of advisees and highlighting their accomplishments reflects on the ability of the educator to guide and promote success in his/her learners.
6. Educational leadership and administration. This is a description of the past and present leadership roles that the educator has held, including courses or clerkships directed. This should allow the educator the opportunity to provide a narrative description of his/her involvement beyond what is typically stated on the curriculum vitae.
7. Professional development. The educator should develop a list of activities, including formal degree programs, certificate programs, and educational workshops, in which he/she has participated as a learner and have enhanced his/her skills as an educator.
8. Products of educational scholarship. Generate a list of education-related peer-reviewed publications authored, other educational products (such as a syllabus or curriculum) developed, and educational workshops that the educator was invited to give.
For clinician educators interested in developing an educator’s portfolio, there are several resources available, including the Academic Pediatric Association’s website and several MedEdPORTAL publications.
Key takeaways for Pediatric HM
• While each institution has its own specific requirements, there are general themes to consider including in an educator’s portfolio.
• Resources such as the Academic Pediatric Association’s website can help guide an educator in the development of his/her portfolio.
Dr. Player is a pediatric hospitalist at Children’s Hospital of Wisconsin and assistant professor at the Medical College of Wisconsin, Milwaukee.
NASHVILLE, TENN. – Development of a medical educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process, according to an expert panel at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Promote yourself: Demonstrating teaching excellence with an educator’s portfolio
Presenters
Michael Ryan, MD, MEHP; Ashlie Tseng, MD; Jocelyn Schiller, MD; Rebecca Tenney-Soeiro, MD, MEd; Michele Long, MD; Corki Lehmann, MD, MEd; Amy Fleming, MD; and H. Barrett Fromme, MD, MHPE
Session summary
Development of an educator’s portfolio is a necessary, but daunting, task for clinician educators when they enter the promotion process. Each institution has its own specific requirements for the educator’s portfolio, but there are several general themes that should be considered for inclusion:
1. Develop an educational philosophy. This is a personal statement that frames the rest of the portfolio and describes how this philosophy is used by the educator in his/her approach to education.
2. Teaching. Include teaching activities that are both formal (i.e. lectures) and sessions that encourage more active participation (i.e. small group discussions). This can be accomplished by generating a teaching activities report, which helps to categorize these activities. This will not only demonstrate the volume of teaching experience, but also help to demonstrate the diversity of an educator’s teaching activities. In this section, an educator also should include teaching awards received.
3. Learner evaluations. A qualitative summary of comments will provide a narrative of the educator’s teaching skills. This section also may include summaries of annual reviews of teaching.
4. Curriculum development. Demonstrate the educator’s active engagement in the development of a novel curriculum or the improvement of a pre-existing curriculum and the successful outcomes of those improvements.
5. Mentoring and advising. Generating a list of advisees and highlighting their accomplishments reflects on the ability of the educator to guide and promote success in his/her learners.
6. Educational leadership and administration. This is a description of the past and present leadership roles that the educator has held, including courses or clerkships directed. This should allow the educator the opportunity to provide a narrative description of his/her involvement beyond what is typically stated on the curriculum vitae.
7. Professional development. The educator should develop a list of activities, including formal degree programs, certificate programs, and educational workshops, in which he/she has participated as a learner and have enhanced his/her skills as an educator.
8. Products of educational scholarship. Generate a list of education-related peer-reviewed publications authored, other educational products (such as a syllabus or curriculum) developed, and educational workshops that the educator was invited to give.
For clinician educators interested in developing an educator’s portfolio, there are several resources available, including the Academic Pediatric Association’s website and several MedEdPORTAL publications.
Key takeaways for Pediatric HM
• While each institution has its own specific requirements, there are general themes to consider including in an educator’s portfolio.
• Resources such as the Academic Pediatric Association’s website can help guide an educator in the development of his/her portfolio.
Dr. Player is a pediatric hospitalist at Children’s Hospital of Wisconsin and assistant professor at the Medical College of Wisconsin, Milwaukee.
At PHM 2017
PHM17 session summary: Kawasaki Disease updates
NASHVILLE, TENN. – A panel of experts discussed highlights from the 2017 AHA Kawasaki Guidelines at Pediatric Hospital Medicine, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Kawasaki Disease Reconsidered: New AHA Guidelines
Presenters
John Darby, MD, Marietta DeGuzman, MD, Kristen Sexson, MD, PhD, MPH, Stanford Shulman, MD, Nisha Tamaskar, MD
Session summary
For the second year in a row, the session highlighting American Heart Association updates on Kawasaki disease did not disappoint and again attracted a large crowd of community and academic pediatric hospitalists. The newly-revised 2017 AHA Kawasaki Guidelines hot off the press by McCrindle et al. was reviewed in detail.
A secondary theory investigates the tropospheric wind patterns from central Asia and has indicated a possible link to outbreaks of KD in Chile. Despite previous investigation of carpet cleaning and risk for KD, no causal link has been identified.
Experts addressed pathophysiology, diagnosis, and management. Below are highlights from the new 2017 AHA Kawasaki Guideline Update in conjunction with points from the panel discussion.
Pathophysiology
• Cause is likely to be a common ubiquitous agent that in genetically inclined children will lead to a particular inflammatory response that manifests clinically as KD.
• A new theory about how the “ubiquitous agent” is spread by wind patterns.
Diagnosis
• Confirmed that infants younger than 1 year of age are more difficult to diagnose because they don’t present classically so it must be on the differential.
• The new algorithm makes it clearer that infants with fever for 7 days without symptoms should get lab screening tests for KD.
• Those who have classic symptoms and lab abnormalities consistent with KD but in whom fever is still at 3-4 days may be diagnosed with KD prior to the “5 days of fever rule” because these tend to be a sicker cohort of patients with higher rate of complications. Pretest probability and suspicion for KD must be high to treat before 5 days.
• Importance of the Z-score when evaluating an echocardiogram completed on a patient with suspected KD was stressed with a score greater than or equal to 2.5 reaching a level of significance for the patient’s body size.
Management
• It is still agreed that IVIG is first line therapy.
• For refractory KD (not responsive within 36 hours of first dose IVIG), management is more controversial. Experts on the panel agreed that they would likely provide a second dose of IVIG before thinking about steroids.
• Moderate dose aspirin is just as effective as high dose aspirin in the acute phase of KD.
• For more detailed information regarding the role of corticosteroids in KD, refer to Dr. Carl Galloway’s article in The Hospitalist July 2017 issue.
• A certain subset of patients may benefit from steroids if given early in the disease course, including those who present in shock syndrome. Steroids would still be in conjunction with IVIG treatment.
• Even though the new guidelines recommend a longer course of steroids for those refractory cases of KD in high-risk patients, panel experts are still unsure about evidence behind the claim.
The RAISE study was referenced and indicates there are significantly different outcomes for patients with severe disease placed on steroid therapy in combination with IVIG. In this group of patients, the incidence of coronary artery aneurysms was 23% in the IVIG-only group compared to 3% in the IVIG + steroid group (P less than .0001). This study and a recent Cochrane review that supported use of steroids in KD were completed in a homogeneous population of Japanese children and may not be generalizable to children in the United States.
Hyponatremia has been used as a diagnostic criterion for severe KD in Japanese children and was referenced as an indicator for addition of steroid therapy. Also, studies investigating the necessity of ASA at 80-100 mg/kg/d, a common practice for patients with KD treated in the United States, were compared to medium-dose ASA (30-50 mg/kg/d). There was no clinically significant difference in patient outcome or development of aneurysm formation between these two dosing regimens.
Key takeaways for Pediatric HM
• Diagnosis of classic KD remains unchanged and includes 5 or more days of fever and at least four clinical features (extremity changes, rash, conjunctivitis, oral changes, and cervical lymphadenopathy).
• Infants with fever of 7 days or more without other explanation should be evaluated for KD.
• Echocardiographic findings should be adjusted for body surface area and are significant if Z-score greater than or equal to 2.5.
• Moderate- to high-dose ASA is appropriate as an adjunct to IVIG until the patient is afebrile.
• Steroid therapy (for a total of 14 days) should be considered for high-risk patients.
Dr. King is associate program director, University of Minnesota Pediatric Residency Program. Dr. Hopkins is assistant professor of pediatrics, Johns Hopkins All Children’s Hospital.
NASHVILLE, TENN. – A panel of experts discussed highlights from the 2017 AHA Kawasaki Guidelines at Pediatric Hospital Medicine, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Kawasaki Disease Reconsidered: New AHA Guidelines
Presenters
John Darby, MD, Marietta DeGuzman, MD, Kristen Sexson, MD, PhD, MPH, Stanford Shulman, MD, Nisha Tamaskar, MD
Session summary
For the second year in a row, the session highlighting American Heart Association updates on Kawasaki disease did not disappoint and again attracted a large crowd of community and academic pediatric hospitalists. The newly-revised 2017 AHA Kawasaki Guidelines hot off the press by McCrindle et al. was reviewed in detail.
A secondary theory investigates the tropospheric wind patterns from central Asia and has indicated a possible link to outbreaks of KD in Chile. Despite previous investigation of carpet cleaning and risk for KD, no causal link has been identified.
Experts addressed pathophysiology, diagnosis, and management. Below are highlights from the new 2017 AHA Kawasaki Guideline Update in conjunction with points from the panel discussion.
Pathophysiology
• Cause is likely to be a common ubiquitous agent that in genetically inclined children will lead to a particular inflammatory response that manifests clinically as KD.
• A new theory about how the “ubiquitous agent” is spread by wind patterns.
Diagnosis
• Confirmed that infants younger than 1 year of age are more difficult to diagnose because they don’t present classically so it must be on the differential.
• The new algorithm makes it clearer that infants with fever for 7 days without symptoms should get lab screening tests for KD.
• Those who have classic symptoms and lab abnormalities consistent with KD but in whom fever is still at 3-4 days may be diagnosed with KD prior to the “5 days of fever rule” because these tend to be a sicker cohort of patients with higher rate of complications. Pretest probability and suspicion for KD must be high to treat before 5 days.
• Importance of the Z-score when evaluating an echocardiogram completed on a patient with suspected KD was stressed with a score greater than or equal to 2.5 reaching a level of significance for the patient’s body size.
Management
• It is still agreed that IVIG is first line therapy.
• For refractory KD (not responsive within 36 hours of first dose IVIG), management is more controversial. Experts on the panel agreed that they would likely provide a second dose of IVIG before thinking about steroids.
• Moderate dose aspirin is just as effective as high dose aspirin in the acute phase of KD.
• For more detailed information regarding the role of corticosteroids in KD, refer to Dr. Carl Galloway’s article in The Hospitalist July 2017 issue.
• A certain subset of patients may benefit from steroids if given early in the disease course, including those who present in shock syndrome. Steroids would still be in conjunction with IVIG treatment.
• Even though the new guidelines recommend a longer course of steroids for those refractory cases of KD in high-risk patients, panel experts are still unsure about evidence behind the claim.
The RAISE study was referenced and indicates there are significantly different outcomes for patients with severe disease placed on steroid therapy in combination with IVIG. In this group of patients, the incidence of coronary artery aneurysms was 23% in the IVIG-only group compared to 3% in the IVIG + steroid group (P less than .0001). This study and a recent Cochrane review that supported use of steroids in KD were completed in a homogeneous population of Japanese children and may not be generalizable to children in the United States.
Hyponatremia has been used as a diagnostic criterion for severe KD in Japanese children and was referenced as an indicator for addition of steroid therapy. Also, studies investigating the necessity of ASA at 80-100 mg/kg/d, a common practice for patients with KD treated in the United States, were compared to medium-dose ASA (30-50 mg/kg/d). There was no clinically significant difference in patient outcome or development of aneurysm formation between these two dosing regimens.
Key takeaways for Pediatric HM
• Diagnosis of classic KD remains unchanged and includes 5 or more days of fever and at least four clinical features (extremity changes, rash, conjunctivitis, oral changes, and cervical lymphadenopathy).
• Infants with fever of 7 days or more without other explanation should be evaluated for KD.
• Echocardiographic findings should be adjusted for body surface area and are significant if Z-score greater than or equal to 2.5.
• Moderate- to high-dose ASA is appropriate as an adjunct to IVIG until the patient is afebrile.
• Steroid therapy (for a total of 14 days) should be considered for high-risk patients.
Dr. King is associate program director, University of Minnesota Pediatric Residency Program. Dr. Hopkins is assistant professor of pediatrics, Johns Hopkins All Children’s Hospital.
NASHVILLE, TENN. – A panel of experts discussed highlights from the 2017 AHA Kawasaki Guidelines at Pediatric Hospital Medicine, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Session
Kawasaki Disease Reconsidered: New AHA Guidelines
Presenters
John Darby, MD, Marietta DeGuzman, MD, Kristen Sexson, MD, PhD, MPH, Stanford Shulman, MD, Nisha Tamaskar, MD
Session summary
For the second year in a row, the session highlighting American Heart Association updates on Kawasaki disease did not disappoint and again attracted a large crowd of community and academic pediatric hospitalists. The newly-revised 2017 AHA Kawasaki Guidelines hot off the press by McCrindle et al. was reviewed in detail.
A secondary theory investigates the tropospheric wind patterns from central Asia and has indicated a possible link to outbreaks of KD in Chile. Despite previous investigation of carpet cleaning and risk for KD, no causal link has been identified.
Experts addressed pathophysiology, diagnosis, and management. Below are highlights from the new 2017 AHA Kawasaki Guideline Update in conjunction with points from the panel discussion.
Pathophysiology
• Cause is likely to be a common ubiquitous agent that in genetically inclined children will lead to a particular inflammatory response that manifests clinically as KD.
• A new theory about how the “ubiquitous agent” is spread by wind patterns.
Diagnosis
• Confirmed that infants younger than 1 year of age are more difficult to diagnose because they don’t present classically so it must be on the differential.
• The new algorithm makes it clearer that infants with fever for 7 days without symptoms should get lab screening tests for KD.
• Those who have classic symptoms and lab abnormalities consistent with KD but in whom fever is still at 3-4 days may be diagnosed with KD prior to the “5 days of fever rule” because these tend to be a sicker cohort of patients with higher rate of complications. Pretest probability and suspicion for KD must be high to treat before 5 days.
• Importance of the Z-score when evaluating an echocardiogram completed on a patient with suspected KD was stressed with a score greater than or equal to 2.5 reaching a level of significance for the patient’s body size.
Management
• It is still agreed that IVIG is first line therapy.
• For refractory KD (not responsive within 36 hours of first dose IVIG), management is more controversial. Experts on the panel agreed that they would likely provide a second dose of IVIG before thinking about steroids.
• Moderate dose aspirin is just as effective as high dose aspirin in the acute phase of KD.
• For more detailed information regarding the role of corticosteroids in KD, refer to Dr. Carl Galloway’s article in The Hospitalist July 2017 issue.
• A certain subset of patients may benefit from steroids if given early in the disease course, including those who present in shock syndrome. Steroids would still be in conjunction with IVIG treatment.
• Even though the new guidelines recommend a longer course of steroids for those refractory cases of KD in high-risk patients, panel experts are still unsure about evidence behind the claim.
The RAISE study was referenced and indicates there are significantly different outcomes for patients with severe disease placed on steroid therapy in combination with IVIG. In this group of patients, the incidence of coronary artery aneurysms was 23% in the IVIG-only group compared to 3% in the IVIG + steroid group (P less than .0001). This study and a recent Cochrane review that supported use of steroids in KD were completed in a homogeneous population of Japanese children and may not be generalizable to children in the United States.
Hyponatremia has been used as a diagnostic criterion for severe KD in Japanese children and was referenced as an indicator for addition of steroid therapy. Also, studies investigating the necessity of ASA at 80-100 mg/kg/d, a common practice for patients with KD treated in the United States, were compared to medium-dose ASA (30-50 mg/kg/d). There was no clinically significant difference in patient outcome or development of aneurysm formation between these two dosing regimens.
Key takeaways for Pediatric HM
• Diagnosis of classic KD remains unchanged and includes 5 or more days of fever and at least four clinical features (extremity changes, rash, conjunctivitis, oral changes, and cervical lymphadenopathy).
• Infants with fever of 7 days or more without other explanation should be evaluated for KD.
• Echocardiographic findings should be adjusted for body surface area and are significant if Z-score greater than or equal to 2.5.
• Moderate- to high-dose ASA is appropriate as an adjunct to IVIG until the patient is afebrile.
• Steroid therapy (for a total of 14 days) should be considered for high-risk patients.
Dr. King is associate program director, University of Minnesota Pediatric Residency Program. Dr. Hopkins is assistant professor of pediatrics, Johns Hopkins All Children’s Hospital.
At PHM 2017
VIDEO: How to discharge new pediatric diabetes cases in 2 days
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NASHVILLE, TENN. – Pediatric endocrinologist Cassandra Brady, MD, caught the attention of her audience at Pediatric Hospital Medicine when she mentioned that children presenting with new-onset diabetes rarely spend more than 2 days at Vanderbilt University’s children’s hospital, even if they present in diabetic ketoacidosis.
In many places, children with new-onset diabetes spend quite a bit longer in the hospital – even if they are medically stable and feeling fine – for diabetes education.
That’s not the case at Vanderbilt, where Dr. Brady is an assistant professor. Once kids are stabilized, they and their parents undergo a 3-hour crash course – sometimes even in the PICU – on diabetes survival skills, and then they’re sent home with insulin. They learn the finer points about carbohydrate counting and tight glucose control at subsequent outpatient visits.
More and more payers are probably going to push for that model, Dr. Brady noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
For those interested in making the transition to outpatient eduction, she explained in an interview exactly how Vanderbilt’s been doing it safely for years.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT PHM 2017
