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Faris N, Mesto M, Mrad S, El Kebbi O, Asi N, Sawaya RD. Applying Topical Anesthetic on Pediatric Lacerations in the Emergency Department: A Quality Improvement Project. Pediatr Emerg Care 2024; 40:175-179. [PMID: 37616570 DOI: 10.1097/pec.0000000000003033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
OBJECTIVES Caring for pediatric lacerations in the emergency department (ED) is typically painful because of irrigation and suturing. To improve this painful experience, we aimed to increase the use of a topical anesthetic, Eutectic Mixture of Local Anesthetics (EMLA) on eligible pediatric lacerations with an attainable, sustainable, and measurable goal of 60%. The baseline rate of applying topical anesthetic to eligible lacerations was 23% in our ED. We aimed to increase the use of topical anesthetics on eligible pediatric lacerations to a measurable goal of 60% within 3 months of implementing our intervention. METHODS We conducted a prospective, single-center, interrupted time series, ED quality improvement project from November 2019 to July 2020. A multidisciplinary team of physicians and nurses performed a cause-and-effect analysis identifying 2 key drivers: early placement of EMLA and physician buy-in on which we built our Plan, Do, Study, and Act (PDSA) cycles. We collected data on number of eligible patients receiving EMLA, as well as patient and physician feedback via phone calls within 2 days after encounter. Balancing measures included ED length of stay (LOS), patient and physician satisfaction with EMLA, and adverse effects of EMLA. RESULTS We needed 3 PDSA cycles to reach our goal of 60% in 3 months, which was also maintained for 5 months. The PDSA cycles used educational interventions, direct provider feedback about noncompliance, and patient satisfaction results obtained via phone calls. Balancing measures were minimally impacted: 75% good patient satisfaction, no adverse events but an increase in LOS of patients who received EMLA compared with those who did not (1.79 ± 0.66 vs 1.41 ± 0.83 hours, P < 0.001). The main reasons for dissatisfaction for physicians were the increased LOS and the preference for procedural sedation or intranasal medications. CONCLUSIONS With a few simple interventions, our aim of applying EMLA to 60% of eligible pediatric lacerations was attained and maintained.
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Affiliation(s)
- Nagham Faris
- From the Department of Emergency Medicine, The American University of Beirut, Beirut, Lebanon
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El Kebbi O, Prather CS, Elmuti L, Khalifeh M, Alali M. High frequency of viridians group streptococci bacteremia in pediatric neuroblastoma high-risk patients during induction chemotherapy. Sci Rep 2023; 13:5627. [PMID: 37024512 PMCID: PMC10079841 DOI: 10.1038/s41598-023-31805-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 03/17/2023] [Indexed: 04/08/2023] Open
Abstract
Existing literature on febrile neutropenia (FN) has categorized patients with acute leukemia or those undergoing allogeneic stem cell transplantation (SCT) as being high risk for severe infection, bacteremia, and poor outcomes. Comprehensive studies of infection risk in pediatric high-risk neuroblastoma (NB-HR) during induction chemotherapy are limited, and mostly merged within the solid tumor (ST) group. Therefore, it is unclear whether infectious complications and outcomes for NB-HR are the same as in other ST groups. We conducted a retrospective medical record review of pediatric FN patients in a single center from March 2009 to December 2016. FN episodes were categorized into five groups based on underlying diagnosis (acute myelogenous leukemia (AML), acute lymphocytic leukemia (ALL), NB-HR during induction chemotherapy, other solid tumors, and SCT). Comparative analyses of infectious complications between patients with NB-HR and those with other types of cancer diagnoses were performed. A total of 667 FN episodes (FNEs) were identified in 230 patients. FNEs occurred in 82 episodes with NB-HR. Bloodstream infection (BSI) occurred in 145 (21.7%) of total FN episodes. The most isolated organisms were the viridians group streptococci (VGS) (25%). NB-HR patients have higher rates of VGS bacteremia (OR 0.15, 95% [CI 0.04, 0.56]) and are more likely to be admitted to the Pediatric Intensive Care Unit (PICU) compared to patients with other solid tumors (OR 0.36, 95% [CI 0.15, 0.84]). Interestingly, there is no difference in VGS rates between patients with NB-HR and those with AML despite the fact that NB-HR patients do not receive a cytosine arabinoside (AraC)-based regimen. This large neuroblastoma cohort showed that patients with NB-HR during induction chemotherapy are at higher risk for VGS bacteremia and PICU admissions compared with patients with other solid tumors. Further prospective studies are needed to investigate infection-related complications in this high-risk group and to improve morbidity and mortality.
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Affiliation(s)
- Ola El Kebbi
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Cassandra S Prather
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lena Elmuti
- Department of Pediatrics, Pediatric Hematology-Oncology, University of Chicago Medicine, Chicago, IL, USA
| | - Malak Khalifeh
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Muayad Alali
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, 705 Riley Hospital Drive, RI-5862, Indianapolis, IN, 46202, USA.
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Oyungu E, El Kebbi O, Vreeman R, Nyandiko W, Monahan PO, Tu W, Khaitan A, Desta Z, Slogrove AL, Humphrey JM, Were E, Patel RC, Carlucci JG, Wools-Kaloustian K, McHenry MS. Predicting neurodevelopmental risk in children born to mothers living with HIV in Kenya: protocol for a prospective cohort study (Tabiri Study). BMJ Open 2022; 12:e061051. [PMID: 35379648 PMCID: PMC8981283 DOI: 10.1136/bmjopen-2022-061051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION For the growing number of children with in utero and postpartum exposure to HIV and/or antiretrovirals, it is unclear which exposures or risk factors play a significant role in predicting worse neurodevelopmental outcomes. This protocol describes a prospective longitudinal cohort study of infants born to mothers living with HIV and those born to mothers without HIV. We will determine which risk factors are most predictive of child neurodevelopment at 24 months. We aim to create a risk assessment tool to help predict which children are at risk for worse neurodevelopment outcomes. METHODS AND ANALYSIS This study leverages an existing Kenyan cohort to prospectively enrol 500 children born to mothers living with HIV and 500 to those without HIV (n=1000 total) and follow them from birth to age 24 months. The following factors will be measured every 6 months: infectious morbidity and biological/sociodemographic/psychosocial risk factors. We will compare these factors between the two groups. We will then measure and compare neurodevelopment within children in both groups at 24 months of age using the Child Behaviour Checklist and the Bayley Scales of Infant and Toddler Development, third edition. Finally, we will use generalised linear mixed modelling to quantify associations with neurodevelopment and create a risk assessment tool for children ≤24 months. ETHICS AND DISSEMINATION The study is approved by the Moi University's Institutional Research and Ethics Committee (IREC/2021/55; Approval #0003892), Kenya's National Commission for Science, Technology and Innovation (NACOSTI, Reference #700244) and Indiana University's Institutional Review Board (IRB Protocol #110990). This study carries minimal risk to the children and their mothers, and all mothers will provide written consent for participation in the study. Results will be disseminated to maternal child health clinics within Uasin Gishu County, Kenya and via papers submitted to peer-reviewed journals and presentation at international conferences.
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Affiliation(s)
- Eren Oyungu
- Department of Medical Physiology, Moi University College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Ola El Kebbi
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon
| | - Rachel Vreeman
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Arnold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Winstone Nyandiko
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Child Health, Moi University College of Health Sciences, Eldoret, Kenya
| | - Patrick O Monahan
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Wanzhu Tu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alka Khaitan
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- Department of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Amy L Slogrove
- Department of Paediatrics & Child Health, Faculty of Medicine & Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - John M Humphrey
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Edwin Were
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Division of Obstetrics and Gynecology, Moi University College of Health Sciences, Eldoret, Kenya
| | - Rena C Patel
- University of Washington School of Medicine, Seattle, Washington, USA
| | - James G Carlucci
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kara Wools-Kaloustian
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Megan S McHenry
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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El-Jardali F, Fadlallah R, Daouk A, Rizk R, Hemadi N, El Kebbi O, Farha A, Akl EA. Barriers and facilitators to implementation of essential health benefits package within primary health care settings in low-income and middle-income countries: A systematic review. Int J Health Plann Manage 2018; 34:15-41. [PMID: 30132987 DOI: 10.1002/hpm.2625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One of the key requirements for achieving universal health coverage is the proper design and implementation of essential health benefits package (EHPs). We systematically reviewed the evidence on barriers and facilitators to the implementation of EHPs within primary health care settings in low-income and middle-income countries. METHODS We searched multiple databases and the gray literature. Two reviewers completed independently and in duplicate data selection, data extraction, and quality assessment. We synthesized the findings according to the following health systems arrangement levels: governance, financial, and delivery arrangements. RESULTS Ten studies met the eligibility criteria. At the governance level, key reported barriers were insufficient policymaker-implementer interactions, limited involvement of consumers and stakeholders, sub-optimal primary health care network arrangement, poor marketing and promotion of package, and insufficient coordination with community network. The key reported facilitator was the presence of a legal policy framework for package implementation. At the financial level, barriers included delays and inadequate remunerations to health care providers while facilitators included government and donor commitments to financing of package and flexibility in exploring new funding mechanisms. At the delivery level, barriers included inadequate supervision, poor facility infrastructure, limited availability of equipment and supplies, and shortages of workers. Facilitators included proper training and management of workforce, availability of female health workers, presence of clearly defined packages, and continuum of care, including referrals to promote comprehensive service delivery. CONCLUSION We identified a set of barriers and facilitators that need to be addressed to ensure proper implementation of EHPs within primary health care settings.
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Affiliation(s)
- Fadi El-Jardali
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Racha Fadlallah
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Aref Daouk
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon.,Staten Island University Hospital, New York, New York, USA
| | - Rana Rizk
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie (INSPECT-LB), Faculty of Public Health, Lebanese University, Lebanon
| | - Nour Hemadi
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Ola El Kebbi
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Aida Farha
- Saab Medical Library, American University of Beirut, Beirut, Lebanon
| | - Elie A Akl
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.,Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
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