A 29-day-old former full-term baby girl presented with 3 days of poor feeding and decreased activity. Her mother reported that the patient had a decreased appetite associated with decreased urine output and stool, but without fever, rhinorrhea, vomiting, diarrhea, or rash. Several family members reportedly had cold symptoms the week prior to presentation. She was born to a 21-year-old mother via uncomplicated normal spontaneous vaginal delivery with no known pregnancy complications. Prenatal infectious labs were reportedly negative including rubella IgG positive, and negative for syphilis, hepatitis B surface antigen, HIV 1 and 2, and group B streptococcus. On presentation to the emergency department, the patient was ill appearing with a temperature of 35.4°C, a weak cry and suck, dry mucous membranes, delayed capillary refill, mottling, and poor respiratory effort. She received fluid resuscitation and supplemental oxygen for respiratory distress. Laboratory findings included a normal complete blood count and urine studies, but her comprehensive metabolic panel (CMP) was significant for elevated aspartate aminotransferase 200 U/L and alanine aminotransferase 102 U/L. A respiratory viral panel was positive for rhinovirus/enterovirus.

Background Peanut allergy has recently become more prevalent. Peanut introduction recommendations have evolved from suggesting peanut avoidance until the age of 3 years to more recent guidelines encouraging early peanut introduction after the Learning Early about Peanut Allergy (LEAP) study in 2015. Guideline adherence is poor, leading to missed care opportunities. Objective In this study, we aimed to develop a user-centered clinical decision support (CDS) tool to improve implementation of the most recent early peanut introduction guidelines in the primary care clinic setting. Methods We edited the note template of the well-child check (WCC) visits at ages 4 and 6 months with CDS prompts and point-of-care education. Formative and summative usability testing were completed with pediatric residents in a simulated electronic health record (EHR). We estimated task completion rates and perceived usefulness of the CDS in summative testing, comparing a test EHR with and without the CDS. Results Formative usability testing with the residents provided qualitative data that led to improvements in the build for both the 4-month and 6-month WCC note templates. During summative usability testing, the CDS tool significantly improved discussion of early peanut introduction at the 4-month WCC visit compared to scenarios without the CDS tool (9/15, 60% with CDS and 0/15, 0% without CDS). All providers except one at the 4-month WCC scenario gave at least an adequate score for the ease of use of the CDS tool for the history of present illness and assessment and plan sections. During the summative usability testing with the 6-month WCC new build note template, providers more commonly provided comprehensive care once obtaining a patient history concerning for an immunoglobulin E–mediated peanut reaction by placing a referral to allergy/immunology (P=.48), prescribing an epinephrine auto-injector (P=.07), instructing on how to avoid peanut products (P<.001), and providing an emergency treatment plan (P=.003) with CDS guidance. All providers gave at least an adequate score for ease of use of the CDS tool in the after-visit summary. Conclusions User-centered CDS improved application of early peanut introduction recommendations and comprehensive care for patients who have symptoms concerning for peanut allergy in a simulation.

Background Maternal influenza immunization has gained traction as a strategy to diminish maternal and neonatal mortality. However, efforts to vaccinate pregnant women against influenza in developing countries will require substantial investment. We present cost-effectiveness estimates of maternal influenza immunization based on clinical trial data from Bamako, Mali. Methods We parameterized a decision-tree model using prospectively collected trial data on influenza incidence, vaccine efficacy, and direct and indirect influenza-related healthcare expenditures. Since clinical trial participants likely had better access to care than the general Malian population, we also simulated scenarios with poor access to care, including decreased healthcare resource utilization and worse influenza-related outcomes. Results Under base-case assumptions, a maternal influenza immunization program in Mali would cost $857 (95% UI: $188-$2358) per disability-adjusted life year (DALY) saved. Adjusting for poor access to care yielded a cost-effectiveness ratio of $486 (95% UI: $105-$1425) per DALY saved. Cost-effectiveness ratios were most sensitive to changes in the cost of a maternal vaccination program and to the proportion of laboratory-confirmed influenza among infants warranting hospitalization. Mean cost-effectiveness estimates fell below Mali's GDP per capita when the cost per pregnant woman vaccinated was $1.00 or less with no adjustment for access to care or $1.67 for those with poor access to care. Healthcare expenditures for lab-confirmed influenza were not significantly different than the cost of influenza-like illness. Conclusions Maternal influenza immunization in Mali would be cost-effective in most settings if vaccine can be obtained, managed, and administered for ô$1.00 per pregnant woman.

Epidemiological studies from sub-Saharan Africa show that genital infection with Schistosoma hematobium may increase the risk for HIV infection in young women. Therefore, preventing schistosomiasis has the potential to reduce HIV transmission in sub-Saharan Africa. We developed a transmission model of female genital schistosomiasis and HIV infections that we fit to epidemiological data of HIV and female genital schistosomiasis prevalence and coinfection in rural Zimbabwe. We used the model to evaluate the cost-effectiveness of a multifaceted community-based intervention for preventing schistosomiasis and, consequently, HIV infections in rural Zimbabwe, from the perspective of a health payer. The communitybased intervention combined provision of clean water, sanitation, and health education (WSH) with administration of praziquantel to school-aged children. Considering variation in efficacy between 10% and 70% of WSH for reducing S. hematobium transmission, our model predicted that community-based intervention is likely to be cost-effective in Zimbabwe at an aggregated WSH cost corresponding to US $725-$1,000 per individual over a 20-y intervention period. These costs compare favorably with empirical measures of WSH provision in developing countries, indicating that integrated community-based intervention for reducing the transmission of S. hematobium is an economically attractive strategy for reducing schistosomiasis and HIV transmission in sub-Saharan Africa that would have a powerful impact on averting infections and saving lives.

Background Despite the heightened risk of serious influenza during infancy, vaccination is not recommended in infants younger than 6 months. We aimed to assess the safety, immunogenicity, and efficacy of maternal immunisation with trivalent inactivated influenza vaccine for protection of infants against a first episode of laboratory-confirmed influenza. Methods We did this prospective, active-controlled, observer-blind, randomised phase 4 trial at six referral centres and community health centres in Bamako, Mali. Third-trimester pregnant women (≥28 weeks' gestation) were randomly assigned (1:1), via a computer-generated, centre-specific list with alternate block sizes of six or 12, to receive either trivalent inactivated influenza vaccine or quadrivalent meningococcal vaccine. Study personnel administering vaccines were not masked to treatment allocation, but allocation was concealed from clinicians, laboratory personnel, and participants. Infants were visited weekly until age 6 months to detect influenza-like illness; laboratory-confirmed influenza diagnosed with RT-PCR. We assessed two coprimary objectives: vaccine efficacy against laboratory-confirmed influenza in infants born to women immunised any time prepartum (intention-to-treat population), and vaccine efficacy in infants born to women immunised at least 14 days prepartum (per-protocol population). The primary outcome was the occurrence of a first case of laboratory-confirmed influenza by age 6 months. This trial is registered with ClinicalTrials.gov, number NCT01430689. Findings We did this trial from Sept 12, 2011, to Jan 28, 2014. Between Sept 12, 2011, and April 18, 2013, we randomly assigned 4193 women to receive trivalent inactivated influenza vaccine (n=2108) or quadrivalent meningococcal vaccine (n=2085). There were 4105 livebirths; 1797 (87%) of 2064 infants in the trivalent inactivated influenza vaccine group and 1793 (88%) of 2041 infants in the quadrivalent meningococcal vaccine group were followed up until age 6 months. We recorded 5279 influenza-like illness episodes in 2789 (68%) infants, of which 131 (2%) episodes were laboratory-confirmed influenza. 129 (98%) cases of laboratory-confirmed influenza were first episodes (n=77 in the quadrivalent meningococcal vaccine group vs n=52 in the trivalent inactivated influenza vaccine group). In the intention-to-treat population, overall infant vaccine efficacy was 33·1% (95% CI 3·7–53·9); in the per-protocol population, vaccine efficacy was 37·3% (7·6–57·8). Vaccine efficacy remained robust during the first 4 months of follow-up (67·9% [95% CI 35·1–85·3] by intention to treat and 70·2% [35·7–87·6] by per protocol), before diminishing during the fifth month (57·3% [30·6–74·4] and 60·7 [33·8–77·5], respectively). Adverse event rates in women and infants were similar among groups. Pain at the injection site was more common in women given quadrivalent meningococcal vaccine than in those given trivalent inactivated influenza vaccine (n=253 vs n=132; p<0·0001), although 354 [92%] reactions were mild. Obstetrical and non-obstetrical serious adverse events were reported in 60 (3%) women in the quadrivalent meningococcal vaccine group and 61 (3%) women in the trivalent inactivated influenza vaccine group. Presumed neonatal infection was more common in infants in the trivalent inactivated influenza vaccine group than in those in the quadrivalent meningococcal vaccine group (n=60 vs n=37; p=0·02). No serious adverse events were related to vaccination. Interpretation Vaccination of pregnant women with trivalent inactivated influenza vaccine in Mali—a poorly resourced country with high infant mortality—was technically and logistically feasible and protected infants from laboratory-confirmed influenza for 4 months. With adequate financing to procure the vaccine, implementation will parallel the access to antenatal care and immunisation coverage of pregnant women with tetanus toxoid. Funding Bill & Melinda Gates Foundation.

Duty hour monitoring is required in accredited training programs, however trainee self-reporting is onerous and vulnerable to bias. The objectives of this study were to use an automated, validated algorithm to measure duty hour violations of pediatric trainees over a full academic year and compare to self-reported violations. Duty hour violations calculated from electronic health record (EHR) logs varied significantly by trainee role and rotation. Block-by-block differences show 36.8% (222/603) of resident-blocks with more EHR-defined violations (EDV) compared to self-reported violations (SRV), demonstrating systematic under-reporting of duty hour violations. Automated duty hour tracking could provide real-time, objective assessment of the trainee work environment, allowing program directors and accrediting organizations to design and test interventions focused on improving educational quality.

Objective: The risk of medical errors increases upon transfer out of the intensive care unit (ICU). Discrepancies in the documented care plan between notes at the time of transfer may contribute to communication errors. We sought to determine the frequency of clinically meaningful discrepancies in the documented care plan for patients transferred from the pediatric ICU to the medical wards and identified risk factors. Materials and Methods: Two physician reviewers independently compared the transfer note and handoff document of 50 randomly selected transfers. Clinically meaningful discrepancies in the care plan between these two documents were identified using a coding procedure adapted from healthcare failure mode and effects analysis. We assessed the influence of risk factors via multivariable regression. Results: We identified 34 clinically meaningful discrepancies in 50 patient transfers. Fourteen transfers (28%) had ≥1 discrepancy, and ≥2 were present in 7 transfers (14%). The most common discrepancy categories were differences in situational awareness notifications and documented current therapy. Transfers with handoff document length in the top quartile had 10.6 (95% CI: 1.2-90.2) times more predicted discrepancies than transfers with handoff length in the bottom quartile. Patients receiving more medications in the 24 hours prior to transfer had higher discrepancy counts, with each additional medication increasing the predicted number of discrepancies by 17% (95% CI: 6%-29%). Conclusion: Clinically meaningful discrepancies in the documented care plan pose legitimate safety concerns and are common at the time of transfer out of the ICU among complex patients.

Rituximab, used in the treatment of some rheumatic and kidney diseases, can lead to hepatitis B virus (HBV) reactivation; HBV screening is recommended for those starting this medication. We aimed to improve by 50% the proportion of patients undergoing HBV screening by implementing multimodal interventions to support clinicians in this evidence-based practice. We conducted a quality improvement project from November 2020 to June 2022 at a tertiary care pediatric hospital system, including patients with rheumatic and/or kidney diseases starting rituximab. Multimodal interventions targeting clinicians included electronic health tools (dot phrase, display of screening recommendations and screening results in rituximab order sets/therapy plans), educational meetings, and e-mail/paper reminders. The primary outcome was the proportion of patients with complete HBV screening, while the secondary outcome was utilization of each laboratory component, tracked using statistical process control charts. Pre- and post-intervention data were compared using Fisher’s test. One hundred eighty-two patients who had been prescribed rituximab were included, of which 98 (54%) were post-intervention. The proportions of patients undergoing complete HBV screening (6% vs. 44%; p < 0.001), HBsAg collection (60% vs. 79%; p = 0.006), anti-HBsAb collection (14% vs. 54%; p < 0.001), and total anti-HBcAb collection (8% vs. 52%; p < 0.001) were significantly higher in the post-intervention period. Improvement was sustained over 18 months, with shifts and/or data points above the control limits in all measures. Forty-five patients were HBV-non-immune. In this study, multimodal interventions including electronic health tools and education of the provider significantly increased the proportion of patients screened for HBV prior to rituximab and identified immunization opportunities.

Introduction: Hospitalized children experience frequent sleep disruptions. We aimed to reduce caregiver-reported sleep disruptions of children hospitalized on the pediatric hospital medicine service by 10% over 12 months. Methods: In family surveys, caregivers cited overnight vital signs (VS) as a primary contributor to sleep disruption. We created a new VS frequency order of "every 4 hours (unless asleep between 2300 and 0500)"as well as a patient list column in the electronic health record indicating patients with this active VS order. The outcome measure was caregiver-reported sleep disruptions. The process measure was adherence to the new VS frequency. The balancing measure was rapid responses called on patients with the new VS frequency. Results: Physician teams ordered the new VS frequency for 11% (1,633/14,772) of patient nights on the pediatric hospital medicine service. Recorded VS between 2300 and 0500 was 89% (1,447/1,633) of patient nights with the new frequency ordered compared to 91% (11,895/13,139) of patient nights without the new frequency ordered (P = 0.01). By contrast, recorded blood pressure between 2300 and 0500 was only 36% (588/1,633) of patient nights with the new frequency but 87% (11,478/13,139) of patient nights without the new frequency (P < 0.001). Overall, caregivers reported sleep disruptions on 24% (99/419) of reported nights preintervention, which decreased to 8% (195/2,313) postintervention (P < 0.001). Importantly, there were no adverse safety issues related to this initiative. Conclusion: This study safely implemented a new VS frequency with reduced overnight blood pressure readings and caregiver-reported sleep disruptions.

Background: Clinical practice guidelines (CPGs) and associated order sets can help standardize patient care and lead to higher-value patient care. However, difficult access and poor usability of these order sets can result in lower use rates and reduce the CPGs’ impact on clinical outcomes. At our institution, we identified multiple CPGs for general pediatrics admissions where the appropriate order set was used in <50% of eligible encounters, leading to decreased adoption of CPG recommendations. Objective: We aimed to determine how integrating disease-specific order groups into a common general admission order set influences adoption of CPG-specific order bundles for patients meeting CPG inclusion criteria admitted to the general pediatrics service. Methods: We integrated order bundles for asthma, heavy menstrual bleeding, musculoskeletal infection, migraine, and pneumonia into a common general pediatrics order set. We compared pre- and postimplementation order bundle use rates for eligible encounters at both an intervention and nonintervention site for integrated CPGs. We also assessed order bundle adoption for nonintegrated CPGs, including bronchiolitis, acute gastroenteritis, and croup. In a post hoc analysis of encounters without order bundle use, we compared the pre- and postintervention frequency of diagnostic uncertainty at the time of admission. Results: CPG order bundle use rates for incorporated CPGs increased by +9.8% (from 629/856, 73.5% to 405/486, 83.3%) at the intervention site and by +5.1% (896/1351, 66.3% to 509/713, 71.4%) at the nonintervention site. Order bundle adoption for nonintegrated CPGs decreased from 84% (536/638) to 68.5% (148/216), driven primarily by decreases in bronchiolitis order bundle adoption in the setting of the COVID-19 pandemic. Diagnostic uncertainty was more common in admissions without CPG order bundle use after implementation (28/227, 12.3% vs 19/81, 23.4%). Conclusions: The integration of CPG-specific order bundles into a general admission order set improved overall CPG adoption. However, integrating only some CPGs may reduce adoption of order bundles for excluded CPGs. Diagnostic uncertainty at the time of admission is likely an underrecognized barrier to guideline adherence that is not addressed by an integrated admission order set.