March 13, 2020
In This Issue

Research Spotlight:
Palliative and End-of-Life Care in Pediatric Settings

CPCE In the News:
New Algorithm Tracks Sepsis Incidence Among Pediatric Patients

Upcoming Events

Recent Publications
Palliative and End-of-Life Care in Pediatric Settings
A series of recent studies by Jennifer Walter, MD, PhD, MS and colleagues investigated several aspects of palliative and end-of-life care in pediatric settings. 

Despite professional recommendations that all residents should have end-of-life and palliative care skills, pediatric residents report inadequate training in some aspects of end-of-life (EOL) care, such as symptom management, communication, and self-care in dealing with grief. Insufficient training in EOL care can negatively impact residents, who report the death of their patients as one of the hardest components of residency. In a retrospective chart review quantifying pediatric residents’ exposure to EOL care, Dr. Walter, Chris Feudtner, MD, PhD, MPH and others identified and described all patient deaths that occurred in a three-year period in one children’s hospital. They found that exposure to EOL care for residents is limited but variable, and suggest designing resident support and education with this variability in mind. 

Clinicians also face high levels of uncertainty when deciding whether to refer a patient or family to specialty palliative care. As part of a pediatric palliative referral intervention for oncology teams, Drs. Walter and Feudtner partnered with Doug Hill, PhD, and Julia Szymczak, PhD to explore how uncertainty might influence palliative care referrals. They conducted a phenomenological qualitative analysis of “uncertainty” as experienced and described by pediatric oncology team members regarding the introduction of palliative care. They found that clinicians caring for patients with advanced cancer encounter seven broad categories of uncertainty: prognostic, informational, individual, communication, relational, collegial, and inter-institutional, each of which can contribute to delays in referring patients to palliative care.

Primary teams may delay consulting subspecialty palliative care, which reduces suffering and improves quality of life for many patients, because of the uncertainty of prognosis. Drs. Walter, Hill, and Feudtner and their team argued for a conceptual model of the challenges and facilitators a clinical team might face in shifting from a restorative-focused treatment plan to one that includes palliative aspects, a transition they call “clinician regoaling.” Recognizing such barriers to transitioning to palliative care at the team level can help clinicians develop strategies for transitioning more effectively when appropriate for their patients.

Along with these studies, Dr. Walter contributed to an editorial responding to a mixed methods multidisciplinary survey about healthcare providers’ (HCPs) perception of communication challenges between team members when caring for chronically critically ill (CCI) children. The study identified team collaboration, continuity, and communication as the highest priorities for improvement. 

Taken together, these studies identify opportunities to improve training in teamwork, communication, and ethics of palliative and end-of-life care. 
New Algorithm Tracks Sepsis Incidence Among Pediatric Patients

Sepsis, a life-threatening organ dysfunction caused by a systemic infection, is a leading cause of mortality and high healthcare costs. In part because the clinical definition of sepsis has evolved in recent years, epidemiological study is challenging. A CHOP team including Fran Balamuth, MD, PhD performed a retrospective study using EHR data for children treated in the emergency department or admitted to CHOP (excluding NICU and cardiac center patients) between January 1, 2011 and January 31, 2019. Working with the DBHi Arcus program, the team developed a sepsis surveillance algorithm. Three iterative reviews by local sepsis experts focused on optimizing sensitivity and specificity of the surveillance criteria. The algorithm was then tested in a separate validation cohort. The algorithm achieved sensitivity of 78% in the derivation cohort and 84% in the validation cohort, results which are comparable to a similar study recently performed with adult patients. Although specificity was lower than the adult study, the CHOP team focused on suspected cases of sepsis rather than randomly selected hospitalizations with a much lower likelihood of including “sepsis-like” cases. The authors acknowledge several limitations, including the fact that the algorithm is intended only for retrospective data and not meant to identify sepsis in real-time, and that the work was performed at a single institution. “However, broader application of this algorithm, if validated in a multicenter study,” they wrote, “could provide an objective, efficient, and reliable method for epidemiologic surveillance of pediatric sepsis.”

“This study is one example of how our program can partner with Arcus and the CHOP Research Institute to become a national leader in sepsis care,” Dr. Balamuth said in a CHOP Press Release. “The next step will be to externally validate the algorithm across different hospitals to make sure that it is not just applicable to CHOP, but at other academic children’s hospitals and community hospitals as well.”

Upcoming Events

CPCE is observing guidance from CHOP and Penn for alternate work arrangements and social distancing due to the novel coronavirus (COVID-19). As a result, the list below looks shorter than usual. Please feel free to contact us with any questions.

Causal Inference Summer Institute
Dates: June 22-25, 2020
Location: Jordan Medical Education Center 5th Floor Law Auditorium, 3400 Civic Center Blvd, Philadelphia
The Center for Causal Inference will host its fourth annual Causal Inference Summer Institute, a four-day, intensive learning experience that will take place at the Perelman School of Medicine, University of Pennsylvania. Each day will offer didactic lectures by experts in the field, discussion of real examples, and hands-on computing sessions. Learn more and register here.
Recent Publications

As cancer treatment can cause gonadal impairment, including acute ovarian failure, Sogol Mostoufi-Moab, MD, MSCE and her colleagues ran a cohort study to develop and validate risk prediction tools to provide accurate clinical guidance for paediatric patients with cancer. They selected two models of acute ovarian failure risk prediction and both performed well. Based on these models, an online risk calculator has been developed for clinical use. These models, along with the online risk calculator, could help clinical discussions regarding the need for fertility preservation intentions in girls and young women diagnosed with cancer.

Brian Fisher, DO, MSCE and colleagues conducted a multicenter retrospective study to describe the incidence of Clostridiodes difficile infection (CDI) in children who have received hematopoietic cell transplantation (HCT) and solid organ transplantation (SOT) and are therefore at increased risk of CDI. Prior history of CDI, proton-pump inhibitors, and exposure to third or fourth generation cephalosporins were identified as risk factors, and fluoroquinolone exposure appeared to be protective.

Children with malignancies undergo recurrent imaging as part of tumor diagnosis, staging and therapy response assessment. Although simultaneous positron emission tomography (PET) and magnetic resonance (MR) allows for decreased radiation exposure and acts as a one-stop shop for disease in which MR imaging is required, it is less readily available than PET/CT across institutions. Hansel Otero, MD contributed to this guide to successful implementation of a clinical pediatric PET/MR program.

Children routinely undergo inhalation induction of general anesthesia. Intravenous line placement, typically done after induction of anesthesia, can be challenging, especially in infants and young children. Aaron Masino, PhD, Tori Sutherland, MD, MPH and colleagues conducted a retrospective observational study to determine whether there was an association between clear liquid fasting time and the number of peripheral intravenous catheter insertion attempts in anesthetized children. They found that clear liquid fasting time was not associated with multiple insertion attempts. Factors such as patient age, ethnicity, time of day of anesthesia induction, and American Society of Anesthesiologists Physical Status classification show a greater association with the risk of multiple intravenous line insertion attempts.

Mental health (MH) services account for a large proportion of healthcare encounters and spending in children. Stephanie Doupnik, MD, MSHP and her colleagues ran a retrospective analysis to examine how characteristics vary between children with any MH diagnosis who have typical spending and the highest spending, identify independent predictors of highest spending, and examine drivers of spending groups. They found that among children with MH conditions, mental and physical health comorbidities were common and spending for general healthcare outpaced spending for MH care.

Poor mental health remains a significant source of morbidity and mortality in the Bhutanese refugee community. Mental Health First Aid (MHFA) is a promising intervention that has been used in other immigrant communities to prepare individuals to recognize and respond to mental health warning signs. In a non-randomized program evaluation, Katherine Yun, MD, MHS and her team examined the effectiveness of training offered with and without culturally-appropriate orientation to mental health terminology and concepts. They recommend developing and systematically evaluating culturally-appropriate orientation materials that introduce mental health vocabulary and conceptualize mental health concepts.

James Guevara, MD, MPH and his team ran a secondary data analysis to determine the association between neighborhood poverty and ADHD severity among children in a large metropolitan area, attributing 2015 American Community Survey census tract poverty to each child’s residential address. They found that neighborhood poverty was not associated with ADHD severity in multivariate analysis, suggesting that factors such as medication use confound the relationship between neighborhood poverty and ADHD severity.

New therapeutic strategies are needed for pediatric acute myeloid leukemia to reduce disease recurrence and treatment-related morbidity. Richard Aplenc, MD, PhD, MSCE, Brian Fisher, DO, MSCE, and their colleagues ran the Children’s Oncology Group Phase III AAML1031 trial to test whether the addition of bortezomib to standard chemotherapy improves survival in pediatric patients with newly diagnosed acute myeloid leukemia. They found that the addition of bortezomib increased toxicity but did not improve survival.

Healthcare systems devote substantial resources to the development of clinical decision support (CDS). Jeremy Michel, MD, MHS and his research team describe how a national repository of CDS can serve as a public resource for healthcare systems, academic researchers, and informaticists seeking to share and reuse CDS knowledge resources or “artifacts,” which could make the process of translating evidence-based practice into effective CDS more efficient. Their analysis indicates that shareable CDS resources reduce team sizes and the number of tasks and time required to design, develop, and deploy CDS. However, the platform requires further optimization to address sociotechnical challenges.

Nicolas Bamat, MD, MSCE and his colleagues sought to examine the effect of off-label surfactant on mortality and morbidity in more mature and larger premature infants diagnosed with respiratory distress syndrome (RDS). They ran a cohort study of premature infants and compared odds of mortality and morbidity between infants who were exposed vs unexposed to surfactant. They found that surfactant exposure is not associated with reduced or increased mortality or morbidity in more mature premature infants with RDS.

Abusive head injuries in infants may be occult but still clinically or forensically important. To quantify yield of computed tomography or magnetic resonance imaging in identification of occult head injuries and evaluate risk factors for occult head injuries, Kate Henry, MD, MSCE, Chris Feudtner, MD, PhD, MPH, Joanne Wood, MD, MSHP, and their colleagues ran a retrospective sample of infants evaluated for physical abuse at 4 urban children’s hospitals in the United States. They found that occult head injuries were less frequent than previously reported in some studies, but were identified in 1 in 10 infants <6 months.

Understanding disparities in child health-related quality of life (HRQoL) may reveal opportunities for targeted improvement. Chén Kenyon, MD, MSHP and his team examined associations between social disadvantage, access to care, and child functioning before and after hospitalization for acute respiratory illness. They found that having social disadvantage markers or difficulty/delays accessing care was associated with lower baseline physical functioning. However, differences were reduced after hospital discharge.

Andrew Steenhoff, MBBCh, DCH, Elizabeth Lowenthal, MD, MSCE, and their team conducted semi-structured interviews with sixteen healthcare workers (HCW) in nine high-burden public tuberculosis (TB) clinics in Gaborone, Botswana and analyzed data using thematic analysis. HCWs supported implementation of youth-friendly services, in addition to health system strengthening. They utilize dedicated approaches for adolescents and young adults (AYA) with TB, but have limited time and resources for optimal care. They identified several strategies likely to improve care and better retain AYAs in TB treatment.

To evaluate the effect of providing early attending physician involvement via telemedicine to improve the decision process of rapid response teams, Christopher Bonafide, MD, MSCE and his colleagues implemented a smartphone-based telemedicine platform to facilitate early co-assessment and disposition planning between the rapid response team at the patient’s bedside and the attending in the ICU. They found more rapid ICU attending involvement via telemedicine was associated with rapid response team providers spending less time outside the ICU, and among patients transferred to the ICU. This marked a significant decrease in likelihood of patients requiring vasopressors or intubation within the first 60 minutes of transfer.

About CPCE

We are a pediatric research center dedicated to discovering and sharing knowledge about best practices in pediatric care by facilitating, organizing and centralizing the performance of clinical effectiveness research -- research aimed at understanding the best ways to prevent, diagnose and treat diseases in children. CPCE’s multidisciplinary team conducts research on a diverse range of clinical effectiveness topics.

CPCE E-News is edited by Holly Burnside. Please feel free to contact us with questions or feedback.