JAMA Pediatrics Current Issue

In This Issue of JAMA Pediatrics

Wed, 01 May 2013 00:00:00 GMT

JAMA Pediatrics Hospital Medicine Theme Issue JAMA Pediatrics Hospital Medicine Theme Issue

Keren R, Shah SS. — Wed, 01 May 2013 00:00:00 GMT

The hospital is a site of increasingly complex and resource-intensive care for children. It is also a clinical setting that in recent years has undergone major changes in the organization, delivery, and financing of care, with reduction in resident work hours, requirements for greater attending oversight of trainees, increased scrutiny of clinical outcomes, new payment models that shift financial risk to health care providers, and new delivery models that attempt to provide greater value for money. This issue of JAMA Pediatrics focuses on hospital medicine, highlighting many of the issues that hospitals will face as they adapt to the rapidly changing health care delivery and financing landscape.

About This Journal

Wed, 01 May 2013 00:00:00 GMT

Application of Business Model Innovation to Enhance Value in Health Care Delivery Application of Business Model Innovation

Fieldston E, Terwiesch C, Altschuler S. — Wed, 01 May 2013 00:00:00 GMT

Faced with the need to improve quality, health care enterprises have used principles from highly reliable industries to make tactical progress. As the health care system faces growing challenges to transform itself, we propose business model innovation as a strategic framework for improving the delivery of health care. We believe that this approach will unify the domains of quality (safety, effectiveness, efficiency, timeliness, patient centeredness, and equity) with the need to enhance value by emphasizing innovation in a manner not traditionally seen in health care.

Association Between Parental Preference and Head Computed Tomography in Children With Minor Blunt Head Trauma

Ishida Y, Manabe A, Oizumi A, et al. — Wed, 01 May 2013 00:00:00 GMT

Natale et al recently reported that race/ethnicity is independently associated with head computed tomography (CT) use among children with minor blunt head trauma. They showed parental anxiety as an important factor influencing head CT orders in non-Hispanic white children regardless of brain injury risk. In a Japanese pediatric cohort of patients with minor blunt head trauma, we conducted a study with similar objectives attempting to identify factors that influence a physician's decision to order a head CT in children.

Decreasing Hospital Length of Stay for Bronchiolitis by Using an Observation Unit and Home Oxygen Therapy Decreasing Hospital LOS for Bronchiolitis

Sandweiss DR, Mundorff MB, Hill T, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Pediatric observation units (OUs) offer the opportunity to safely and efficiently care for common illnesses previously cared for in an inpatient setting. Home oxygen therapy (HOT) has been used to facilitate hospital discharge in patients with hypoxic bronchiolitis. It is unknown how implementation of a hospitalwide bronchiolitis treatment protocol promoting OU-HOT would affect hospital length of stay (LOS).

Objective

To test the hypothesis that using OU-HOT for bronchiolitis would decrease LOS.

Design and Setting

Retrospective cohort study at Primary Children's Medical Center, Salt Lake City, Utah.

Participants

Uncomplicated bronchiolitis patients younger than 2 years admitted during the winter seasons of 2005 through 2011.

Interventions

Implementation of a new bronchiolitis care process encouraging use of an OU-HOT protocol.

Main Outcome Measures

Mean hospital LOS, discharge within 24 hours, emergency department (ED) bronchiolitis admission rates and ED revisit/readmission rates, and inflation-adjusted cost.

Results

A total of 692 patients with bronchiolitis from the 2010-2011 bronchiolitis season were compared with 725 patients from the 2009-2010 season. Implementation of an OU-HOT protocol was associated with a 22.1% decrease in mean LOS (63.3 hours vs 49.3 hours, P < .001). Although LOS decreased during all 6 winter seasons, linear regression and linear quantile regression analyses for the 2005-2011 LOS data demonstrated a significant acceleration in the LOS decrease for the 2010-2011 season after implementation of the OU-HOT protocol. Discharges within 24 hours increased from 20.0% to 38.4% (P < .001), with no difference in ED bronchiolitis admission or ED revisit/readmission rates. After implementation of the OU-HOT protocol, the total cost per admitted case decreased by 25.4% ($4800 vs $3582, P < .001).

Conclusions and Relevance

Implementation of an OU-HOT protocol for patients with bronchiolitis safely reduces hospital LOS with significant cost savings. Although widespread implementation has the potential for dramatic cost savings nationally, further studies assessing overall health care use and cost, including the impact on families and outpatient practices, are needed.

Family-Centered Advance Care Planning for Teens With Cancer ACP for Teens With Cancer

Lyon ME, Jacobs S, Briggs L, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Advance care planning (ACP) prepares patients and their families for future health care decisions; however, the needs of adolescent oncology patients for participation in ACP have not been well studied.

Objective

To examine the efficacy of family-centered ACP.

Design and Setting

Two-group randomized controlled trial in a pediatric oncology program.

Participants

Sixty adolescents aged 14 to 21 years with cancer and their surrogates or families were enrolled in the study between January 17, 2011, and March 29, 2012.

Intervention

Thirty dyads received 3- to 60-minute sessions 1 week apart. Intervention dyads completed (1) the Lyon Family-Centered ACP Survey, (2) the Respecting Choices interview, and (3) Five Wishes. Control subjects received standard care plus information.

Main Outcome Measures

Statement of treatment preferences and Decisional Conflict Scale score.

Results

The mean age of the adolescents was 16 years; 36 (60%) were male, 30 (50%) white, 26 (43%) black, and 4 (7%) Asian. Diagnoses were as follows: leukemia (14 patients [47%]), brain tumor (8 [27%]), solid tumor (6 [20%]), and lymphoma (2 [7%]). Significantly increased congruence was observed for intervention dyads compared with controls for 4 of the 6 disease-specific scenarios; for example, for situation 2 (“treatment would extend my life by not more than 2 to 3 months”), intervention dyads demonstrated higher congruence (κ = 0.660; P < .001) vs control dyads (κ = −0.0636; P = .70). Intervention adolescents (100%) wanted their families to do what is best at the time, whereas fewer control adolescents (62%) gave families this leeway. Intervention adolescents were significantly better informed about end-of-life decisions (t = 2.93; effect size, 0.961; 95% CI, 0.742-1.180; P = .007). Intervention families were more likely to concur on limiting treatments than controls. An ethnic difference was found in only one situation.

Conclusions

Advance care planning enabled families to understand and honor their adolescents' wishes. Intervention dyads were more likely than controls to limit treatments. Underserved African American families were willing to participate.

H. I. E.

Williams J. — Wed, 01 May 2013 00:00:00 GMT

You are G-tube, trach-dependent,deaf, blind, devastated, orphaned, forgotten,and 2 years old today.You are an incredible teacher.You arecerebral palsy,septic shock,multidrug-resistant organisms,broad-spectrum antibiotics,pulmonary edema,acute renal failure,fluid resuscitation,epinephrine,chest compressions,epinephrine,sinus tachycardia.I wonder . . . do you dream?Of peppermint breezes and thrumming valleys,burning bushes and albino woods,bottomless sun and twisting caverns,marshmallow clouds and rose-petal rains.Of swiftwater farms with slow-flowing tricklesover cotton rocks past hand-dripped castlesunder deafening moonrises through endless timewithout shadow.Without a shadow.Of a doubt.You are neither a carrot nor a cucumber.What gift can I give you?I will still say “good morning” when I enter your room.Good.Mourning.Happy birthday.

If Your Child Is Hospitalized: The Hospital Health Care Team

Moreno MA, Rivara FP. — Wed, 01 May 2013 00:00:00 GMT

If your child needs to be in the hospital, it can be a stressful and confusing experience. In many hospitals, there are multiple people involved in the care of each pediatric patient, and it can be challenging for parents to keep track of who is who. I outline the typical medical and nursing team members, and suggest ways to interact with your child's hospital health care team.

Influence of Obesity on Clinical Outcomes in Hospitalized Children A Systematic Review Obesity and Outcomes in Hospitalized Children

Bechard LJ, Rothpletz-Puglia P, Touger-Decker R, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Obesity is prevalent among hospitalized children. Knowledge of the relationship between obesity and outcomes in hospitalized children will enhance nutrition assessment and provide opportunities for interventions.

Objective

To systematically review the existing literature concerning the impact of obesity on clinical outcomes in hospitalized children.

Evidence Acquisition

PubMed, Web of Science, and EMBASE databases were searched for studies of hospitalized children aged 2 to 18 years with identified obesity and at least 1 of the following clinical outcomes: all-cause mortality, incidence of infections, and length of hospital stay. Cohort and case-control studies were included. Cross-sectional studies, studies of healthy children, and those without defined criteria for classifying weight status were excluded. The Newcastle-Ottawa Scale was used to assess study quality.

Results

Twenty-eight studies (26 retrospective; 24 cohort and 4 case-control) were included. Of the 21 studies that included mortality as an outcome, 10 reported a significant positive relationship between obesity and mortality. The incidence of infections was assessed in 8 of the 28 studies; 2 reported significantly more infections in obese compared with nonobese patients. Of the 11 studies that examined length of stay, 5 reported significantly longer lengths of hospital stay for obese children. Fifteen studies (53%) had a high quality score. Larger studies observed significant relationships between obesity and outcomes. Studies of critically ill, oncologic or stem cell transplant, and solid organ transplant patients showed a relationship between obesity and mortality.

Conclusions and Relevance

The available literature on the relationship between obesity and clinical outcomes is limited by subject heterogeneity, variations in criteria for defining obesity, and outcomes examined. Childhood obesity may be a risk factor for higher mortality in hospitalized children with critical illness, oncologic diagnoses, or transplants. Further examination of the relationship between obesity and clinical outcomes in this subgroup of hospitalized children is needed.

Influence of Surgeon Experience, Hospital Volume, and Specialty Designation on Outcomes in Pediatric Surgery A Systematic Review Factors Affecting Outcomes in Pediatric Surgery

McAteer JP, LaRiviere CA, Drugas GT, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Analyses of volume-outcome relationships in adult surgery have found that hospital and physician characteristics affect patient outcomes, such as length of stay, hospital charges, complications, and mortality. Similar investigations in children's surgical specialties are fewer in number, and their conclusions are less clear.

Objective

To review the evidence regarding surgeon or hospital experience and their influence on outcomes in children's surgery.

Evidence Review

A MEDLINE and EMBASE search was conducted for English-language studies published from January 1, 1980, through April 13, 2012. Titles and abstracts were screened in a standardized manner by 2 reviewers. Studies selected for inclusion had to use a measure of hospital or surgeon experience as a predictor variable and had to report postoperative outcomes as dependent response variables. Included studies were reviewed with regard to methodologic quality, and study results were extracted.

Findings

Sixty-three studies were reviewed. Significant heterogeneity was detected in exposure definitions, outcome measures, and risk adjustment, with the greatest heterogeneity seen in appendectomy studies. Various exposure levels were examined: hospital level in 48 (68%) studies, surgeon level in 11 (17%), and both in 9 (14%). Nineteen percent of studies did not adjust for confounding, and 57% did not adjust for sample clustering. The most consistent methods and reproducible results were seen in the pediatric cardiac surgical literature. Forty-nine studies (78%) showed positive correlation between experience and most primary outcomes, but differences in outcomes and exposure definitions made comparisons between studies difficult. In general, hospital-level factors tended to correlate with outcomes for high-complexity procedures, whereas surgeon-level factors tended to correlate with outcomes for more common procedures.

Conclusions and Relevance

Data on experience-related outcomes in children's surgery are limited in number and vary widely in methodologic quality. Future studies should seek both to standardize definitions, making results more applicable, and to differentiate procedures affected by surgeon experience from those more affected by hospital resources and system-level variables.

Multi-institutional Profile of Adults Admitted to Pediatric Intensive Care Units Adults in Pediatric Intensive Care Units

Edwards JD, Houtrow AJ, Vasilevskis EE, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Growing numbers of persons with childhood-onset chronic illnesses are surviving to adulthood. Many use pediatric hospitals for their inpatient needs. To our knowledge, the prevalence and characteristics of adult pediatric intensive care unit patients have not been reported.

Objectives

To estimate the proportion of adults admitted to pediatric intensive care units (PICUs), characterize them, and compare them with older adolescents.

Design

One-year cross-sectional analysis.

Setting

Pediatric intensive care units in the United States that participated in the Virtual Pediatric Intensive Care Unit Systems.

Participants

Pediatric intensive care unit patients 15 years or older admitted in 2008.

Main Outcome Measures

We compared adults with adolescents across clinical characteristics and outcomes. Mixed-effects logistic regression was used to estimate the independent association of age with PICU mortality.

Results

Seventy PICUs had 67 629 admissions; 1954 admissions (2.7%) were patients 19 years or older; and 9105 admissions (13.5%) were patients aged 15 to 18 years. The proportion of adults (≥19 years) varied considerably by PICU (range, 0%-9.2%). As age increased, the proportion of patients who had a complex chronic condition and planned or perioperative admissions increased; the proportion of trauma-related admissions decreased. Patients aged 21 to 29 years had a 2 times (95% CI, 1.3-3.2; P = .004) greater odds of PICU mortality compared with adolescent patients, after adjusting for Paediatric Index of Mortality score, sex, trauma, and having a complex chronic condition. Being 30 years or older was associated with a 3.5 (95% CI, 1.3-9.7; P = .01) greater odds of mortality.

Conclusions and Relevance

In this multi-institutional study, adults constituted a small but high-risk proportion of patients in some PICUs, suggesting that these PICUs should have plans and protocols specifically focused on this group.

Neurodevelopmental Outcomes of Extremely Low-Gestational-Age Neonates With Low-Grade Periventricular-Intraventricular Hemorrhage Outcomes of Neonates With Ventricular Hemorrhage

Payne AH, Hintz SR, Hibbs A, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Low-grade periventricular-intraventricular hemorrhage is a common neurologic morbidity among extremely low-gestational-age neonates, yet the outcomes associated with this morbidity are not fully understood. In a contemporary multicenter cohort, we evaluated the impact of such hemorrhages on early (18-22 month) neurodevelopmental outcomes of extremely premature infants.

Objective

To compare neurodevelopmental outcomes at 18 to 22 months' corrected age for extremely low-gestational-age infants with low-grade (grade 1 or 2) periventricular-intraventricular hemorrhage with those of infants with either no hemorrhage or severe (grade 3 or 4) hemorrhage demonstrated on cranial ultrasonography.

Design

Longitudinal observational study.

Setting

Sixteen centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network.

Participants

A total of 1472 infants born at less than 27 weeks' gestational age between January 1, 2006, and December 31, 2008, with ultrasonography results within the first 28 days of life and surviving to 18 to 22 months with complete follow-up assessments were eligible.

Main Exposure

Low-grade periventricular-intraventricular hemorrhage.

Main Outcome Measures

Outcomes included cerebral palsy; gross motor functional limitation; cognitive and language scores according to the Bayley Scales of Infant Development, 3rd Edition; and composite measures of neurodevelopmental impairment. Regression modeling evaluated the association of hemorrhage severity with adverse outcomes while controlling for potentially confounding variables and center differences.

Results

Low-grade hemorrhage was not associated with significant differences in unadjusted or adjusted risk of any adverse neurodevelopmental outcome compared with infants without hemorrhage. Compared with low-grade hemorrhage, severe hemorrhage was associated with decreased adjusted continuous cognitive (β, −3.91 [95% CI, −6.41 to −1.42]) and language (β, −3.19 [−6.19 to −0.19]) scores as well as increased odds of each adjusted categorical outcome except severe cognitive impairment (odds ratio [OR], 1.46 [0.74 to 2.88]) and mild language impairment (OR, 1.35 [0.88 to 2.06]).

Conclusions and Relevance

At 18 to 22 months, the neurodevelopmental outcomes of extremely low-gestational-age infants with low-grade periventricular-intraventricular hemorrhage are not significantly different from those without hemorrhage. Additional study at school age and beyond would be informative.

Nurse Staffing and NICU Infection Rates Nurse Staffing and NICU Infection Rates

Rogowski JA, Staiger D, Patrick T, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

There are substantial shortfalls in nurse staffing in US neonatal intensive care units (NICUs) relative to national guidelines. These are associated with higher rates of nosocomial infections among infants with very low birth weights.

Objective

To study the adequacy of NICU nurse staffing in the United States using national guidelines and analyze its association with infant outcomes.

Design

Retrospective cohort study. Data for 2008 were collected by web survey of staff nurses. Data for 2009 were collected for 4 shifts in 4 calendar quarters (3 in 2009 and 1 in 2010).

Setting

Sixty-seven US NICUs from the Vermont Oxford Network, a national voluntary network of hospital NICUs.

Participants

All inborn very low-birth-weight (VLBW) infants, with a NICU stay of at least 3 days, discharged from the NICUs in 2008 (n = 5771) and 2009 (n = 5630). All staff-registered nurses with infant assignments.

Exposures

We measured nurse understaffing relative to acuity-based guidelines using 2008 survey data (4046 nurses and 10 394 infant assignments) and data for 4 complete shifts (3645 nurses and 8804 infant assignments) in 2009-2010.

Main Outcomes and Measures

An infection in blood or cerebrospinal fluid culture occurring more than 3 days after birth among VLBW inborn infants. The hypothesis was formulated prior to data collection.

Results

Hospitals understaffed 31% of their NICU infants and 68% of high-acuity infants relative to guidelines. To meet minimum staffing guidelines on average would require an additional 0.11 of a nurse per infant overall and 0.34 of a nurse per high-acuity infant. Very low-birth-weight infant infection rates were 16.4% in 2008 and 13.9% in 2009. A 1 standard deviation–higher understaffing level (SD, 0.11 in 2008 and 0.08 in 2009) was associated with adjusted odds ratios of 1.39 (95% CI, 1.19-1.62; P < .001) in 2008 and 1.40 (95% CI, 1.19-1.65; P < .001) in 2009.

Conclusions and Relevance

Substantial NICU nurse understaffing relative to national guidelines is widespread. Understaffing is associated with an increased risk for VLBW nosocomial infection. Hospital administrators and NICU managers should assess their staffing decisions to devote needed nursing care to critically ill infants.

Pediatric Hospital Medicine

Wed, 01 May 2013 00:00:00 GMT

Pediatric Hospital Medicine, 2013. Cassio Lynm, MA, CMI.

Pediatric Hospital Medicine and Education Why We Can't Stand Still Pediatric Hospital Medicine and Education

Maniscalco J, Fisher E. — Wed, 01 May 2013 00:00:00 GMT

Pediatric hospital medicine (PHM), as it is known now, has arrived. It is no longer merely a movement, nor is it only a reaction to residency work-hour restrictions or a call for heightened attention to safety for increasingly acute and complex hospitalized children. It is a well-defined field of pediatrics, dedicated to improving the care of hospitalized children, both at the point of care and through systemwide transformations. It requires a specialized knowledge base and skill set to practice with efficiency and expertise. It is the professional choice for approximately 2500 practicing pediatricians in the United States (C. Collier, Society of Hospital Medicine, written and oral communication, February 2012; and N. Alexander, American Academy of Pediatrics, written and oral communication, October 2012), an active and forward-thinking community supported by 3 partner organizations (the American Academy of Pediatrics, Academic Pediatric Association, and Society of Hospital Medicine) and guided by the Joint Council of Pediatric Hospital Medicine, a coordinating body among these organizations.

Picture of the Month—Diagnosis

Wed, 01 May 2013 00:00:00 GMT

Picture of the Month—Quiz Case

Tebruegge M, Sukhtankar P, Patel S, et al. — Wed, 01 May 2013 00:00:00 GMT

A 17-year-old boy presented to our hospital with a 4-week history of pain and restriction of movement in his left shoulder. Two weeks prior to presentation, he had developed a skin lesion on the anterior aspect of the same shoulder. At that point, radiographs of the shoulder (Figure 1) and chest (Figure 2) were obtained. It was assumed that he had a superficial skin infection, which prompted treatment with amoxicillin–clavulanate potassium without improvement.

Prognostic Significance of Low-Grade Intraventricular Hemorrhage in the Current Era of Neonatology Prognostic Significance of Low-Grade IVH

Sola-Visner M. — Wed, 01 May 2013 00:00:00 GMT

Cranial ultrasonography (CUS) is performed routinely in extremely preterm infants admitted to the neonatal intensive care unit (NICU), and periventricular-intraventricular hemorrhages (PIVHs) are found in approximately 30% of infants born at less than 29 weeks' gestation. Compared with infants with no hemorrhages, infants with intraventricular hemorrhages leading to ventricular dilatation (grade 3 in the Papile classification) or infants with intraparenchymal hemorrhages (grade 4) clearly have higher incidences of cerebral palsy and worse cognitive outcomes. However, the significance of isolated small hemorrhages confined to the germinal matrix (grade 1) or of intraventricular hemorrhages without ventricular dilatation (grade 2) has been less clearly established. Studies evaluating the outcome of infants with these findings have been sparse and have yielded controversial results, and thus there is variability in how the significance of these low-grade hemorrhages is interpreted by neonatologists and conveyed to the parents.

Risk Factors for Peripherally Inserted Central Venous Catheter Complications in Children Risk Factors for PICC Complications in Children

Jumani K, Advani S, Reich NG, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Peripherally inserted central venous catheters (PICCs) are prone to infectious, thrombotic, and mechanical complications. These complications are associated with morbidity, so data are needed to inform quality improvement efforts.

Objectives

To characterize the epidemiology of and to identify risk factors for complications necessitating removal of PICCs in children.

Design

Cohort study.

Setting

Johns Hopkins Children's Center, Baltimore, Maryland.

Participants

Hospitalized children who had a PICC inserted outside of the neonatal intensive care unit (ICU) from January 1, 2003, through December 31, 2009.

Main Outcome Measures

Complications necessitating PICC removal as recorded by the PICC Team.

Results

During the study period, 2574 PICCs were placed in 1807 children. Complications necessitating catheter removal occurred in 534 PICCs (20.8%) during 46 021 catheter-days (11.6 complications per 1000 catheter-days). These included accidental dislodgement (4.6%), infection (4.3%), occlusion (3.7%), local infiltration (3.0%), leakage (1.5%), breakage (1.4%), phlebitis (1.2%), and thrombosis (0.5%). From 2003 to 2009, complications decreased by 15% per year (incidence rate ratio [IRR], 0.85; 95% CI, 0.81-0.89). In adjusted analysis, all noncentral PICC tip locations—midline (IRR 4.59, 95% CI, 3.69-5.69), midclavicular (2.15; 1.54-2.98), and other (3.26; 1.72-6.15)—compared with central tip location were associated with an increased risk of complications. Pediatric ICU exposure and age younger than 1 year were independently associated with complications necessitating PICC removal.

Conclusions and Relevance

Noncentral PICC tip locations, younger age, and pediatric ICU exposure were independent risk factors for complications necessitating PICC removal. Despite reductions in PICC complications, further efforts are needed to prevent PICC-associated complications in children.

Suctioning and Length of Stay in Infants Hospitalized With Bronchiolitis Suctioning in Bronchiolitis

Mussman GM, Parker MW, Statile A, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Hospitalizations of infants for bronchiolitis are common and costly. Despite the high incidence and resource burden of bronchiolitis, the mainstay of treatment remains supportive care, which frequently includes nasal suctioning.

Objective

To examine the association between suctioning device type and suctioning lapses greater than 4 hours within the first 24 hours after hospital admission on length of stay (LOS) in infants with bronchiolitis.

Design

Retrospective cohort study. Data were extracted from the electronic health record.

Setting

Main hospital and satellite facility of a large quaternary care children's hospital from January 10, 2010, through April 30, 2011.

Participants

A total of 740 infants aged 2 to 12 months and hospitalized with bronchiolitis.

Main Outcome Measure

Hospital LOS.

Results

In the multivariable model adjusted for inverse weighting for propensity to receive deep suctioning, increased deep suction as a percentage of suction events was associated with increased LOS with a geometric mean of 1.75 days (95% CI, 1.56-1.95 days) in patients with no deep suction and 2.35 days (2.10-2.62 days) in patients with more than 60% deep suction. An increased number of suctioning lapses was also associated with increased LOS in a dose-dependent manner with a geometric mean of 1.62 days (95% CI, 1.43-1.83 days) in patients with no lapses and 2.64 days (2.30-3.04 days) in patients with 3 or 4 lapses.

Conclusions and Relevance

For patients admitted with bronchiolitis, the use of deep suctioning in the first 24 hours after admission and lapses greater than 4 hours between suctioning events were associated with longer LOS.

Tackling Taboo Topics How to Have Effective Advanced Care Planning Discussions With Adolescents and Young Adults With Cancer Tackling Taboo Topics

Walter JK, Rosenberg AR, Feudtner C. — Wed, 01 May 2013 00:00:00 GMT

How can we clinicians talk about important but scary topics with patients and their parents? More specifically, for adolescents and young adults with cancer, how can we best engage them in advanced care planning (ACP) in a timely manner, especially in light of the reluctance by patients, families, and clinicians to open up this conversation? These are important questions: if the disease advances and the adolescent or young adult patient is no longer able to participate in decision making, then the parents or other family members will be called on for guidance regarding the medical choices the patient would have made, providing a so-called substituted judgment on behalf of the patient. Yet, frequently parents and family members do not know in sufficient detail what the patient would have wanted. Discussions that would have clarified these issues are often avoided or postponed because they are often felt to be too scary, depressing, or daunting. Indeed, getting patients and families to have these conversations has been a major hurdle since ACP was first advocated more than 20 years ago. So what to do?

The Reason I Am

Gurzu S. — Wed, 01 May 2013 00:00:00 GMT

I have forgotten the painI have forgotten the woundsThe pain of unsleeping nightsThe wounds of failed exams;I am a physician nowI am the patients' hopeTheir teardrops move me.I became a reason for the suffering childrenI became a champion for my friendsA strange, tired but amazing child for my parentsAn eternal busy motherAnd, for sure, a hard-to-understand wife.All of these because I chose to be a physician,And I swore to be skilled in my jobBecause I like my career, I like childrenAnd I want to bring them back to health.Please, forgive me for my neglectTry to understand and let me be forthrightAnd I promise to beA real mother, although eternally busyA real wife, although sometimes hard to understandA good, but strange, child for my parentsAnd also, a champion physician.