Pediatrics
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Pediatric hospitalist systems are being implemented widely. Their implementation may be influenced by physician attitudes, which may vary according to practice type (eg, community or hospital-based practice) and personal characteristics (eg, age and practice location). Little evidence exists to describe factors relevant to pediatric systems. The objective of this study was to determine physicians' attitudes regarding hospitalists and associated physician and practice characteristics. ⋯ Attitudes regarding hospitalist systems differ between physician groups and are influenced by practice characteristics. Understanding these differences and tailoring hospitalist systems to address them will be important as pediatric hospitalist systems are implemented nationwide.
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Respiratory syncytial virus (RSV) bronchiolitis is a common cause of hospitalizations in children and has been increasingly identified as a risk factor in the development of asthma. Little is known about what determines the severity of RSV bronchiolitis, which may be helpful in the initial assessment of these children. ⋯ The severity of RSV bronchiolitis early in life seems modified by postnatal maternal cigarette smoke exposure and atopy and age of the infant, not by levels of allergens in the home environment.
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Patient safety indicators (PSIs) were developed by the Agency for Healthcare Research and Quality. Our objectives were (1) to apply these algorithms to the National Association of Children's Hospitals and Related Institutions (NACHRI) Aggregate Case Mix Comparative Database for 1999-2002, (2) to establish mean rates for each of the PSI events in children's hospitals, (3) to investigate the inadequacies of PSIs in relation to pediatric diagnoses, and (4) to express the data in such a way that children's hospitals could use the PSIs determined to be appropriate for pediatric use for comparison with their own data. In addition, we wanted to use the data to set priorities for ongoing clinical investigations and to propose interventions if the indicators demonstrated preventable errors. ⋯ PSIs derived from administrative data are indicators of patient safety concerns and can be relevant as screening tools for children's hospitals; however, cases identified by these indicators do not always represent preventable events. Some, such as a foreign body left in during a procedure, iatrogenic pneumothorax, infection attributable to medical care, decubitus ulcer, and venous thrombosis, seem to be appropriate for pediatric care and may be directly amenable to system changes. Evidence-based practices regarding those particular indicators that have been reported in the adult literature need to be investigated in the pediatric population. In their present form, 2 of the indicators, namely, failure to rescue and death in low-mortality DRGs, are inaccurate for the pediatric population, do not represent preventable errors in the majority of pediatric cases, and should not be used to estimate quality of care or preventable deaths in children's hospitals. The PSIs can assist institutions in prioritizing chart review-based investigations; if clusters of validated events emerge in reviews, then improvement activities can be initiated. Large aggregate databases, such as the NACHRI Case Mix Database, can help establish mean rates of potential pediatric events, giving children's hospitals a context within which to examine their own data.
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The Institute of Medicine's report When Children Die emphasizes the importance of the medical home in end-of-life care, but no research has been conducted from this perspective. Identifying types and locations of patient deaths from the perspective of the medical home is important for developing the needed psychosocial support and addressing the longitudinal needs of bereaved families and staff members. ⋯ The wide diversity of patient ages and types and causes of deaths suggests that medical home sites need end-of-life services that are flexible enough to meet the individual needs of bereaved families and staff members. The greater relative mortality rate and higher proportion of patients with underlying medical conditions, compared with national data, suggest a greater burden of disease in this continuity setting. Medical home sites should consider tracking systems to identify patients who have died. Future research needs to identify the barriers to patients dying at home and to study the impact of patient deaths on medical home staff members.
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American children's ready access to firearms contributes to high rates of firearm-related injuries. Understanding the factors that influence storage decisions is critical for prevention. This study examined the influence of geography and presence of children <16 years old in the home on firearm-ownership and storage decisions of northeast-Ohio residents. ⋯ These results illustrate the inadequacy of 1-size-fits-all interventions and highlight the need to better understand gun owners' reasoning about children and guns to design and implement successful interventions. Physicians and others interested in reducing pediatric exposure to firearms cannot be credible messengers on gun-safety topics if they cannot demonstrate an understanding of the issues from the perspective of patients and their families.