Posted On: January 30, 2012

Controlling Infections in Pediatric ICUs

Hospital infections have been a hot topic for a few years now, and most hospitals have made strides toward cleaning up their microbial act. A recent story in Consumer Reports, however, presents a bad news-goods news scenario about hospital-acquired infections in pediatric intensive care units.

Pediatric ICUs, the consumer group found, often have higher infection rates than ICUs for adults. The most threatening infections are delivered by catheters, tubes that provide nutrition, fluids and medication. If not inserted and managed under completely sterile conditions, they can spread infection throughout the body. In 2009, 1 in 4 of such infections were fatal.

Children are more susceptible to infection because their immune systems are less developed. And the very ill kids in ICUs are particularly vulnerable.

Part of the difficult of infection control, Consumer Reports said, concerns lack of information: “Of the 423 pediatric intensive-care units in the U.S., information on bloodstream infection rates is publicly available for less than half.” You cannot solve a problem of which you’re unaware.

By analyzing information from 92 pediatric ICUs in 31 states and Washington, D.C., Consumer Reports concluded that they carried an infection rate 20 percent higher than national rates for adult ICUs.

That’s the bad news. The good news is that parents can do something to minimize the chances of their child contracting an infection courtesy of the ICU.

If your child requires ICU care, and if your proximity, doctor’s admitting privileges and insurance coverage permit you to choose among hospitals, examine their respective infection rates as charted on the Consumer Reports website.

In choosing a pediatrician, find out where he or she has admitting privileges, and how those hospitals have performed.

If you don’t have the luxury of choice—and even if you do—here’s the Consumer Reports prescription for keeping infections at bay.

Ask the staff how you can help. A nurse has several patients to care for; parents have one. Watch that the central line stays clean, and that everyone in contact with it scrubs it clean and uses sterile equipment to access it.

Make sure the hospital follows best practices for inserting and maintaining central lines. This means disinfecting the site and changing the dressings regularly and standardizing procedures for changing the catheter caps and tubes. Following a regular routine with the proper tools is more protective than re-inventing the wheel each time. It’s not your job to know each of the steps; simply asking about them can remind staff to be extra vigilant about adhering to the safety measures.

Ask if the central line is still needed. Smaller veins can make it more difficult to insert catheters into a child, so sometimes doctors prefer to leave it in until they’re sure it’s no longer necessary. And once a child has a central line, often it’s used for blood samples, reducing a child’s exposure to traumatic needle sticks. Those practices can be good medicine, but they’re not without risk.

Keep hands clean. Make sure you, visitors and the hospital staff wash their hands with soap or an alcohol-based solution before touching your child or the catheter.

Watch the catheter. The line can come into contact with a diaper; a fidgeting child might put the lines in his or her mouth.

Take notes. Keep track of how often hospital staff change the catheter or dressing and how long the catheter has been in.

Raise an alarm. If something seems amiss, trust your instincts. Voice them and make sure someone responds.

Share your story. If you or someone you care for has been harmed by a hospital-acquired infection, contact Consumer Union’s Safe Patient Project, which raises awareness about hospital safety. That site offers a wealth of information about how patients can influence their care and that of their loved ones in positive ways.

Another resource for hospital patients, and potential patients, is Consumer Reports hospital survival guide.

Also, see our Web page on hospital monitoring.

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Posted On: January 24, 2012

Assessing the Quality of Hospital Care for Children with Asthma

Every year, more than 1.8 million people find themselves in a hospital emergency room to treat an asthma attack. Children account for nearly half that number, and of asthmatic people who go from the ER to an overnight hospital stay, more than 1 in 3 are kids.

As reported in the Patient Safety America Newsletter, three criteria to analyze the quality of care for children hospitalized for an asthma attack have been defined by the Joint Commission, an agency charged with assessing and regulating hospital practices. It also certifies health-care organizations and programs.

The measures of acceptable emergency treatment for asthma are:

  • drugs to relieve the acute symptoms;

  • administering corticosteroids to reduce inflammation; and

  • development of a complete home management plan.

These measures were studied and the results published in the Journal of the American Medical Association. Investigators looked at the records of more than 37,000 children treated in 30 children’s hospitals to determine how well those facilities complied with the treatment criteria and whether compliance reduced hospital readmissions or subsequent ER visits.

The news, mostly, was good—the first two measures notched 97% and 90% rates of compliance respectively.

The bad news lay in the follow-up: Compliance with a home management plan averaged only about 4 in 10 cases. But investigators determined that failure to comply with this measure had no effect on the rates of readmission or visits to the emergency room seven, 30 or 90 days after discharge from the hospital. Compliance did increase over the time in which measurements were compiled (early 2008 through the third quarter of 2010), so the state of this art appears to be improving.

But this curious outcome begs the question: If readmission/ER visits didn’t appear to be affected by noncompliance, why is No. 3 a quality measure at all?

Study authors offered several possible reasons for the lack of association between home-care follow-up and finding yourself back at the hospital.
1. The study didn’t look at how well the plan was implemented at home, nor could the investigators determine whether asthma patients were admitted to another hospital after their visit to the initial hospital.
2. Patients or their parents might not have understood the home-care plan and how to implement it. A commentary on this study noted that there is a "gulf" between patient-centered plans involving coaching and timely follow-up with parents, and often there is no written plan.
3. Readmission measures might be insensitive to the quality of care a child with asthma receives at home. Is it is time to search for other quality measures of care received by hospitalized children with asthma?

So if you’re the parent of a child with potentially life-threatening asthma, here’s how you can improve the chances of getting the best care should the need for an ER visit arise.

  • Identify in advance a nearby children’s hospital; it’s more likely to follow quality measures than a general hospital.

  • When your child is discharged, make sure you understand the follow-up care plan. There is no such thing as a dumb question. If the information isn’t offered in printed form, ask for it or take careful notes.

  • Get the name and contact information of someone who can answer any questions you have after you leave.

  • Inform your pediatrician of the care plan.

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Posted On: January 15, 2012

Some Emergency Departments Deprive Injured Children of Effective Pain Relief

Anyone who has suffered a broken bone knows how painful it can be. Long bone fractures—those involving arms and legs—are common among children. Any parent wants to spare his or her kid from the intense pain of such an injury, but a recent study published in Academic Emergency Medicine has bad news in that regard.

Thanks to the crowded conditions in hospital emergency rooms, administering pain medication to children with long bone fractures is less effective and not as timely as it should be.

Researchers from the University of Colorado School of Medicine studied 1,229 patients treated in the emergency department of an academic children’s hospital for one year. They found that patients were 4 to 47 percent less likely to receive timely care and 3 to 17 percent less likely to receive effective care when the ER was crowded.

Previous studies have shown that adults consigned to crowded emergency rooms also get lower levels of pain meds. This study appears to be the first to investigate the affect of crowding on children with fracture-related pain.

It’s pretty much a no-brainer. As the lead author said, “When the emergency department gets busier, staff may be less responsive to the needs of individual patients, and as a result, patients have a higher likelihood of nontreatment and delays in treatment.”

Still, it’s not simply a function of too many people seeking care in an overburdened ER: Sometimes it’s hospital procedure. In some emergency departments, only doctors are authorized to prescribe pain meds, in others nurses are allowed to administer them to patients meeting certain criteria.

If the ER is crowded, the solution is to hire more staff. If that’s not feasible in this era of cut, cut, cut, the researchers say hospitals must “leverage the staff [they] have,” which means revising pain-management procedures by allowing nurses to administer analgesics and computers or phones to signal under-treated pain.

Because overcrowding is often the result of people seeking treatment for something that isn’t an emergency, the solution must be one of policy as well as practice. As the researchers said, “We as a nation need to get serious about this. Crowding needs to be a policy priority at every level.”

There should be incentives for patients to seek care at their own doctor’s office, including better compensation for primary care and disincentives for nonemergency use of emergency departments.

The best a parent can do is to anticipate the routine, if painful, medical emergencies children are disposed to experience. Call your doctor before you ever need ER attention, and ask him or her how you can ensure that your child receives pain mitigation in the event he breaks his leg at 9 o’clock at night.

  • Should you leave a message with his or her answering service asking him or her to run interference before you reach the hospital?

  • Are there are other measures you should take to cut through the crowd and get some relief?

  • Is being a squeaky wheel in the ER a good thing, or counterproductive?

No one wants to prolong a child’s pain; it’s a matter of finding a work-around when too many voices are clamoring for too few ears.

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Posted On: January 9, 2012

Panel Says There Is No "Safe" Amount of Lead in Children's Bodies

Even though the number of lead poisoning cases is declining, the toxic metal remains a problem, particularly for children, as we have written about numerous times, most recently last week.

A federal panel, the Advisory Committee on Childhood Lead Poisoning Prevention, recently expressed its concern about blood levels in children by advocating for a lower acceptable threshold.

If adopted, it would be the first time in 20 years the Centers for Disease Control and Prevention (CDC) lowers the standard. The CDC has never failed to accept a panel advisory.

Lower blood level standards, as reported on the Huffington Post, would result in hundreds of thousands more children diagnosed with lead poisoning. The new blood level for children would be 5 micrograms of lead per deciliter versus the previous value of 10 micrograms.

Lead used to be a common component of paint and gasoline, but the metal has long been banned in the manufacture of both.

Children’s developing organs are particularly vulnerable to lead, especially the brain and kidneys. Depending on the blood level, lead can cause reduced intelligence, behavioral problems, impaired hearing, coma, convulsions and death.

Children often are exposed if they live in old, deteriorating homes or those undergoing renovation. The delivery systems include paint chips, lead-filled dust and soil contaminated by leaded gasoline.

As the panel’s report made clear, all children are at risk: “New findings suggest that the adverse health effects of BLLs [blood lead levels] less than 10 μg/dL in children extend beyond cognitive function to include cardiovascular, immunological, and endocrine effects. Additionally, such effects do not appear to be confined to lower socioeconomic status populations.

“Primary prevention is a strategy that emphasizes the prevention of lead exposure, rather than a response to exposure after it has taken place. Primary prevention is necessary because the effects of lead appear to be irreversible.”

Lowering the acceptable lead level in blood is a welcome adjustment for childrens’ advocates, who say that medical evidence has been mounting that even lower levels of lead poisoning can erode a child's ability to learn and cause behavior problems.

"This is long overdue," Ruth Ann Norton told the Huffington Post. She’s executive director of the Coalition to End Childhood Lead Poisoning in Baltimore.

The challenge in implementing the panel’s recommendations lies in the languishing economy. Many city and county health departments are responsible for providing services for lead-poisoned kids, and according to the Huffington Post, those departments have lost more than 34,000 jobs in the last three years because of budget cuts. And Congress has slashed the CDC's lead program from more than $30 million to $2 million.

Parents should be aware of the advisory panel’s recommendations for monitoring lead blood levels in children. If your ob/gyn and pediatrician don’t broach the subject, you should. The panel advises:

  • Primary prevention must start with counseling, including prenatal if possible. This includes recommending environmental assessments for children before screening BLLs in children at risk for lead exposure.

  • After confirmatory testing, children above the reference value of 5 μg/dL must continue to be monitored for BLLs and assessed for iron deficiency and general nutrition (for example, calcium and vitamin C levels) consistent with American Academy of Pediatrics (AAP) guidelines.

  • Iron-deficient children should be provided with iron supplements. All BLL test results should be communicated to families in a timely and appropriate manner.

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Posted On: January 2, 2012

Unusual Sources of Lead Poisoning for Parents to Watch Out For

Although significant strides have been made toward eliminating the threat of lead poisoning, the National Capital Poison Center points out that it is still a problem, especially for children.

Symptoms of lead poisoning can range from the relatively mild—abdominal discomfort—to the dire—seizures, coma and death. Children exposed to too much lead also can have lower IQ scores, difficulty with reading and math and behavioral problems including attention deficit disorders and delinquency.

Because some sources of the deadly metal are unexpected, the Poison Center has enumerated certain products for which parents should be especially watchful. They are:

  • Jewelry and Cosmetics. Some imported cosmetics have been contaminated with lead, including kohl (used as eye liner) and sindoor (a red scalp powder).

  • Imported medicines, traditional medicines and folk remedies. Azarcon and greta are used to treat empacho (stomach symptoms); both contain a substantial amount of lead. In one study, 64 percent of herbal medicines from India contained lead, which also shows up in folk remedies for arthritis, infertility, cramps and colic. Contaminated medicines might have been imported, or purchased overseas and brought into the U.S. by consumers.

  • Imported food and candy. Tamarind candy and candy wrappers from Mexico have been contaminated with lead. Several spices and food products imported from India have been contaminated with lead.

  • Bullets, lead pellets and hobby items. Licking bullets, swallowing lead pellets or shot or breathing fumes from melted lead for fishing weights can cause lead poisoning.

  • Household items. Children have been poisoned by lead when acidic foods were stored or served on imported ceramic dishware and pitchers—acid promotes the leaching of lead from the ceramic glaze into the food. Lead poisoning has resulted from contaminated plastic mini-blinds. Curtain weights may contain lead. Antique cribs and furniture may be sources of lead-based paint.

Any lead is too much lead: There is no “normal” blood level. Children with lead exposure often complain of stomach pain, are fussy, can’t concentrate and have diminished appetite. The only way to diagnose lead poisoning is by a blood test.

To minimize the chances of your child being exposed to lead:

  • Do not purchase inexpensive metal jewelry for children. In addition to lead, some also contain the toxic metal cadmium.

  • Verify the source and safety of imported cosmetics and medicines, especially traditional and folk medicines, or don’t use them.

  • Don’t allow children to lick or suck on hobby materials including bullets, pellets, fishing sinkers.

  • Do not use imported ceramic plates, pitchers, etc. to store or serve food. Use them for decoration only.

  • Replace old, plastic mini-blinds.

  • If you live in a building constructed before the 1980s, consider having the paint tested for lead content, and also consider getting free lead blood screening tests for any children in the house. Here is more information from the U.S. Consumer Products Safety Commission on lead in housing.

To address concerns or questions about lead or the treatment of lead poisoning, call 800-222-1222. Local poison center experts answer phone call 24 hours a day.

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