Acute gastroenteritis is one of the leading causes of emergency department (ED) visits for children, accounting for more than 1.7 million trips each year. Its standard treatment has traditionally been rehydration by giving fluids orally or intravenously. Though both methods are equally effective, oral rehydration is preferred as it results in less discomfort and helps stop diarrhea sooner. The IV route is often employed in children who are vomiting and unable or unwilling to drink a large amount of liquids.
About a decade ago, ED physicians began orally administering the anti-nausea medication ondansetron to vomiting patients with gastroenteritis who were unable to hold down oral fluids. Once the ondansetron has stemmed their nausea, children have a much easier time with oral rehydration.
However, the lack of standardized use of this drug has led to its overuse. Though intended to reduce the use of IV rehydration, ondansetron proved so effective at reducing vomiting that its use skyrocketed in the course of just a few years.
Bronchiolitis, a common respiratory illness among infants, is responsible for hundreds of thousands of emergency department (ED) visits each year. Best practices for managing it, established by the Academy of American Pediatrics (AAP), are fairly simple: Offer supportive therapies and let the disease runs its course, as most interventions have little or no benefit for these patients.
But despite these guidelines, bronchiolitis costs the U.S. health care system millions of dollars a year, much of that cost coming from unnecessary diagnostic tests such as chest x-rays and respiratory syncytial virus (RSV) testing.
“When a mother comes to the ED with a baby who is having difficulty breathing, it can be very frightening for her,” says Boston Children’s Hospital’s Ayobami Akenroye, MBChB, MPH,lead author of a study looking at resource utilization of bronchiolitis patients, recently published by Pediatrics. “In many cases, to help alleviate worry and ensure everything is being done to help the child, EDs will order various tests and sometimes give medication to temporarily relieve symptoms, but rarely do any of these steps impact how care is delivered or affect the clinical course of the disease. They’re usually unnecessary.”
Throughout the world, a child is born with a cleft lip or palate nearly every three minutes. In resource-poor areas, many of these children die before their first birthday, and those who survive have difficulty eating, speaking and being accepted by their peers.
Lauren Mednick, PhD, a pediatric psychologist at Boston Children’s Hospital, knows this all too well. As a child life specialist with Operation Smile, she was part of a medical missionary team that traveled the world providing safe, effective reconstructive surgery and treatment to children with clefts and other facial deformities.
Working closely with these children and their families, Mednick was amazed at how many of them blamed the child’s condition on themselves, the supernatural or a combination of the two. She listened as a mother in Morocco “confessed” that her baby had been born with a cleft lip, because she looked at an animal with a cloven hoof during her pregnancy. She sat with a Haitian woman who attributed her child’s cleft lip to an afternoon when she spent too long looking at a child in her village with a facial deformity.
In the not-too-distant past, the medical community wasn’t overly concerned about the quality of life of adults with cystic fibrosis (CF). It’s not that doctors were callous; the life expectancy for the disease was just so low that the vast majority of CF patients never lived to see adulthood. But improved understanding and management of the disease in the past 30 years has changed that.
On average patients with CF are living into their late 30s, up 85 percent from the early 1980s. Today, more than 40 percent of all CF patients in America are more than 18 years old.
Medical errors are a leading cause of death and injury in America, and an estimated 80 percent of serious medical errors involve some form of miscommunication, particularly during the transfer of care from one provider to the next. However, a study published this week in the Journal of the American Medical Association demonstrates that standardizing written and verbal communication during these patient “handoffs” can substantially reduce medical errors without burdening existing workflows.
The study followed 1,255 patient admissions to two separate inpatient units at Boston Children’s Hospital—half occurring before a new verbal and written handoff program was introduced (July to September 2009) and half after (from November 2009 to January 2010).
After implementation, providers spent more time communicating face-to-face in quiet areas conducive to conversation. There were fewer omissions or miscommunications about patient data during handoffs. And medical errors decreased 45.8 percent.
But she never fancied herself an innovator—until recently. After participating in Hacking Pediatrics, sponsored by Boston Children’s Hospital in collaboration with MIT’s H@cking Medicine, she now sees potential innovations and innovators everywhere.
“To be an innovator, you don’t need to be extraordinary, you just need to recognize that a problem exists and be dedicated to fixing it,” she says.
The problem she took to last month’s Hacking Pediatrics Hackathon stems directly from her work. As co-medical director at Boston Children’s Eosinophilic Gastrointestinal Disease (EGID) Program, which treats specific food allergies causing gastrointestinal inflammation, she sees families constantly struggling to find new (and healthy) meals that won’t trigger an allergic reaction in their kids.
“Many of our patients can only safely eat a handful of foods, so feeding them with any kind of variety is extremely hard,” she says. “Then if you factor in the likes, dislikes and other food intolerances that often exist in a family, just planning one family meal can feel like a nightmare.”
Government agencies in charge of determining what constitutes efficient, quality health care have taken to looking at hospital readmission rates. On the surface, this makes perfect sense: If patients are continually being readmitted to a hospital, that hospital must not be doing enough to treat patients appropriately on the first go-round. But new research indicates that relying too heavily on readmissions as an efficiency metric may wrongly put some health care institutions—particularly pediatric hospitals—at a disadvantage.
At the American Academy of Pediatrics (AAP) meeting this week, a team led by James Gay, MD, medical director of Utilization and Case Management at Monroe Carell Jr. Children’s Hospital at Vanderbilt, presented research involving more than 1 million patients cared for at children’s hospitals across the country. The team, which also included Boston Children’s Mark Neuman, MD, MPH, posed this question: If hospital ratings are going to be tied so strongly to readmission rates, shouldn’t that rating system recognize the difference between potentially preventable readmissions (PPRs) and those that are unavoidable?
Currently, some state Medicaid programs use software such as 3M PPR, developed for this exact purpose. Like the basic idea that inspired it, the 3M PPR system works well on principle. However, according to Gay and colleagues, it doesn’t capture all the nuances of what makes a readmission preventable or not.
For decades, patients have managed their type 1 diabetes by injecting themselves with insulin to regulate the glucose in their blood. While this form of medical management addresses the immediate danger of low insulin levels, long-term complications associated with diabetes, like heart and kidney diseases, still threaten more than 215,000 children currently living with the disease in the United States.
“Insulin injections can manage hyperglycemia by reducing the patient’s glucose levels, but it is not the cure,” says Paolo Fiorina, MD, PhD, of the Nephrology Division at Boston Children’s Hospital.
Fiorina is currently involved in new research targeting a molecular pathway that triggers diabetes in the first place—potentially providing a permanent cure. It could potentially change the face of diabetes treatment in children.
As an infant, Cameron Ledin sneezed and rubbed his eyes whenever his mother, Kim, nursed him. His growth was slow, and as he got older, it became clear that he had serious feeding problems. When he was old enough for solid foods, he refused to eat. When he was old enough to speak, he complained that eating hurt his stomach.
Over the years, Cameron saw allergy specialists at Boston Children’s Hospital repeatedly, and every visit ended with more confirmed food allergies. By the time he was 7, Cameron could eat only 25 foods, and his pain and symptoms continued. Multiple tests—for airway, pulmonary and upper digestive tract problems—had inconclusive results.
After an organ transplant, patients need to adjust to a lot of strict routines. This is hard, especially for teenagers who are trying to navigate adolescence. Some young patients say it’s difficult to remember when they need to take all their medications to prevent organ rejection, especially when they’re not feeling ill. Others complain that their parents’ constant harping to follow their care team’s instructions makes them want to do the exact opposite.
No matter the reason, thousands of teenagers are at risk of compromising their grafted organ.
Researchers at Boston Children’s Pediatric Transplant Center are developing a smartphone application that they hope will help adolescents understand the importance of taking care of themselves. But they realize that it’s not enough to take a clinical approach and it give an app makeover. In other words, to truly make an impact on teenagers, the app needs to be more than an electronic version of their parents.
“We really need to create ways to communicate with young patients that’s right for their age and treatment stage,” says Kristine McKenna, PhD, a psychologist with the Pediatric Transplant Center. “If you’re too patriarchal, or if you try to dumb things down too much, teens pick up on that and resent it. But if it’s too high-level they can become overwhelmed.”