Outcomes of Ileoanal Pouch Anastomosis in Pediatric Ulcerative Colitis Are Worse in the Modern Era: A Time Trend Analysis Outcomes Following Ileal Pouch-Anal Anastomosis in Pediatric Ulcerative Colitis

BACKGROUND

Despite significant differences in surgical outcomes between pediatric and adult patients with ulcerative colitis (UC) undergoing colectomy, counseling on pediatric outcomes has largely been guided by data from adults. We compared differences in pouch survival between pediatric and adult patients who underwent total proctocolectomy with ileal pouch-anal anastomosis (IPAA).

METHODS

This was a retrospective single-center study of patients with UC treated with IPAA who subsequently underwent pouchoscopy between 1980 and 2019. Data were collected via electronic medical records. We stratified the study population based on age at IPAA. Differences between groups were assessed using t tests and chi-square tests. Kaplan-Meier curves were used to compare survival probabilities. Differences between groups were assessed using a log-rank test.

RESULTS

We identified 53 patients with UC who underwent IPAA before 19 years of age and 329 patients with UC who underwent IPAA at or after 19 years of age. Subjects who underwent IPAA as children were more likely to require anti-tumor nerosis factor (TNF) postcolectomy compared with adults (41.5% vs 25.8%; P < .05). Kaplan-Meier estimates revealed that pediatric patients who underwent IPAA in the last 10 years had a 5-year pouch survival probability that was 28% lower than that of those who underwent surgery in the 1990s or 2000s (72% vs 100%; P < .001). Further, children who underwent IPAA and received anti-TNF therapies precolectomy had the most rapid progression to pouch failure when compared with anti-TNF-naive children and with adults who were either exposed or naive precolectomy (P < .05).

CONCLUSIONS

There are lower rates of pouch survival for children with UC who underwent IPAA following the uptake of anti-TNF therapy compared with both historical pediatric control subjects and contemporary adults.

Development and External Validation of a Machine Learning Model for Prediction of Potential Transfer to the PICU

OBJECTIVES

Unrecognized clinical deterioration during illness requiring hospitalization is associated with high risk of mortality and long-term morbidity among children. Our objective was to develop and externally validate machine learning algorithms using electronic health records for identifying ICU transfer within 12 hours indicative of a child's condition.

DESIGN

Observational cohort study.

SETTING

Two urban, tertiary-care, academic hospitals (sites 1 and 2).

PATIENTS

Pediatric inpatients (age <18 yr).

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Our primary outcome was direct ward to ICU transfer. Using age, vital signs, and laboratory results, we derived logistic regression with regularization, restricted cubic spline regression, random forest, and gradient boosted machine learning models. Among 50,830 admissions at site 1 and 88,970 admissions at site 2, 1,993 (3.92%) and 2,317 (2.60%) experienced the primary outcome, respectively. Site 1 data were split longitudinally into derivation (2009-2017) and validation (2018-2019), whereas site 2 constituted the external test cohort. Across both sites, the gradient boosted machine was the most accurate model and outperformed a modified version of the Bedside Pediatric Early Warning Score that only used physiologic variables in terms of discrimination ( C -statistic site 1: 0.84 vs 0.71, p < 0.001; site 2: 0.80 vs 0.74, p < 0.001), sensitivity, specificity, and number needed to alert.

CONCLUSIONS

We developed and externally validated a novel machine learning model that identifies ICU transfers in hospitalized children more accurately than current tools. Our model enables early detection of children at risk for deterioration, thereby creating opportunities for intervention and improvement in outcomes.

Objective Measures of Physical Distancing in the Hospital During the COVID-19 Pandemic

During the COVID-19 pandemic, hospitals published physical-distancing guidance and created dedicated respiratory isolation units (RIUs) for patients with COVID-19. The degree to which such distancing occurred between clinicians and patients is unknown. In this study, heat sensors from an existing hospital hand-hygiene monitoring system objectively tracked room entries as a proxy for physical distancing in both RIUs and general medicine units before and during the pandemic. The RIUs saw a 60.6% reduction in entries per room per day (from 85.7 to 33.8). General medicine units that cared for patients under investigation for COVID-19 and other patients experienced a 14.7% reduction in entries per room per day (from 76.9 to 65.1). While gradual extinction was observed in both units as COVID-19 cases declined, the RIUs had a higher degree of physical distancing. Although the optimal level of physical distancing is unknown, sustaining physical distancing in the hospital may require re-education and real-time monitoring.

The impact of the COVID-19 pandemic on nighttime room entries and sleep disruptions for pediatric patients

Objectives/background

Sleep is critical to recovery, but inpatient sleep is often disrupted. During the COVID-19 pandemic, social distancing efforts to minimize spread may have improved hospitalized children's sleep by decreasing unnecessary overnight disruptions. This study aimed to describe the impact of these efforts on pediatric inpatient sleep using objective and subjective metrics.

Methods

Sleep disruptions for pediatric inpatients admitted prior to and during the COVID-19 pandemic were compared. Hand hygiene sensors tracking room entries were utilized to measure objective overnight disruptions for 69 nights pre-pandemic and 154 pandemic nights. Caregiver surveys of overnight disruptions, sleep quantity, and caregiver mood were adopted from validated tools: the Karolinska Sleep Log, Potential Hospital Sleep Disruptions and Noises Questionnaire, and Visual Analog Mood Scale.

Results

Nighttime room entries initially decreased 36% (95% CI: 30%, 42%, p < 0.001), then returned towards baseline, mirroring the COVID-19 hospital census. However, surveyed caregivers (n_pre = 293, n_post = 154) reported more disrupted sleep (p < 0.001) due to tests (21% vs. 38%), anxiety (23% vs. 41%), and pain (23% vs. 48%). Caregivers also reported children slept 61 fewer minutes (95% CI: −12 min, −110 min, p < 0.001). Caregivers self-reported feeling more sad, weary, and worse overall (p < 0.001 for all).

Conclusions

Despite a decrease in objective room entries during the pandemic, caregivers reported their children were disrupted more and slept less. Caregivers also self-reported worse mood. This highlights the effects of the COVID-19 pandemic on subjective experiences of hospitalized children and their caregivers. Future work targeting stress and anxiety could improve pediatric inpatient sleep.

646 The Impact of the COVID-19 Pandemic on Nighttime Room Entries and Sleep Disruptions for Pediatric Patients

Introduction

Sleep is critical to children’s health and recovery, but pediatric inpatient sleep is often disrupted by nonessential overnight interruptions. The COVID-19 pandemic necessitated social distancing policies which minimized contact with low-risk patients. These policies have the potential to decrease overnight disruptions and improve sleep for hospitalized patients.

Methods

This cohort study compared sleep disruptions for pediatric inpatients admitted prior to (Sep 2018 – Feb 2020) and during (Apr 2020 – Aug 2020) the COVID-19 pandemic at a single site, urban academic medical center. Objective disruptions were measured as room entries detected by hand hygiene sensors for occupied rooms pre-pandemic (n_average=56) and during the pandemic (n_average=48) for 69 and 154 nights, respectively. Subjective reports of overnight disruptions, sleep quantity, and caregiver mood were measured by surveys adopted from validated tools: the Karolinska Sleep Log, Potential Hospital Sleep Disruptions and Noises Questionnaire, and Visual Analog Mood Scale. Caregivers of a convenience sample of pediatric general medicine inpatients completed surveys. Caregivers pre-pandemic were surveyed in person, and during the pandemic, surveys were conducted over the phone.

Results

293 pre-pandemic (age_patients=4.1±4.4 years) and 154 pandemic (age_patients=8.7±5.6 years) surveys were collected from caregivers. The majority (71% pre-pandemic and 52% pandemic) of the study population identified as Black/African American. Nighttime room entries initially decreased 36% (95% CI: 30%, 42%, p&lt;0.001), then returned towards pre-pandemic levels as the COVID-19 hospital caseload decreased. Despite this, caregivers reported more disrupted patient sleep (p&lt;0.001) due to tests (21% vs. 38%) as well as stress (30% vs. 49%), anxiety (23% vs. 41%), and pain (23% vs. 48%). Caregivers also reported children slept 61 minutes less (95% CI: 12 min, 110 min, p&lt;0.001) and had more awakenings. Caregivers self-reported feeling more sad and weary, less calm, and worse overall (p&lt;0.001 for all).

Conclusion

Despite fewer objective room entries, caregivers reported increased sleep disruptions and an hour less nighttime sleep with more awakenings during the pandemic for pediatric patients. Caregivers also self-reported worse mood. This highlights the importance of addressing subjective perceptions and experiences of hospitalized children and their caregivers during hospitalization.

Support (if any):

Improving Hospitalized Children's Sleep by Reducing Excessive Overnight Blood Pressure Monitoring

BACKGROUND

Although required for healing, sleep is often disrupted during hospitalization. Blood pressure (BP) monitoring can be especially disruptive for pediatric inpatients and has few clinical indications. Our aim in this pilot study was to reduce unnecessary overnight BP monitoring and improve sleep for pediatric inpatients.

METHODS

The intervention in June 2018 involved clinician education sessions and updated electronic health record (EHR) orders that enabled the forgoing of overnight BP checks. The postintervention period from July 2018 to May 2019 examined patient-caregiver surveys as outcome measures. These surveys measured inpatient sleep and overnight disruptions and were adopted from validated surveys: the Patient Sleep Questionnaire, expanded Brief Infant Sleep Questionnaire, and Potential Hospital Sleep Disruptions and Noises Questionnaire. Uptake of new sleep-friendly EHR orders was a process measure. Reported patient care escalations served as a balancing measure.

RESULTS

Interrupted time series analysis of EHR orders (n_pre = 493; n_post = 1472) showed an increase in intercept for the proportion of patients forgoing overnight BP postintervention (+50.7%; 95% confidence interval 41.2% to 60.3%; P < .001) and a subsequent decrease in slope each week (-0.16%; 95% confidence interval -0.32% to -0.01%; P = .037). Statistical process control of surveys (n_pre = 263; n_post = 131) showed a significant increase in sleep duration for patients older than 2, and nighttime disruptions by clinicians decreased by 19% (P < .001). Annual estimated cost savings were $15 842.01. No major adverse events in patients forgoing BP were reported.

CONCLUSIONS

A pilot study combining EHR changes and clinician education safely decreased overnight BP checks, increased pediatric inpatient sleep duration, and reduced nighttime disruptions by clinicians.