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Objective To test the hypothesis that hopeful patterns of thoughts and emotions of parents of pediatric patients receiving palliative care consultative services are related to subsequent decisions, specifically regarding limit of intervention (LOI) orders. Design Prospective cohort study. Setting Children's hospital and surrounding region. Participants Thirty-three pediatric patients receiving palliative care consultative services who did not have LOI orders at time of cohort entry and their 43 parental adults. Main Exposures Parental levels at time of cohort entry of hopeful patterns of thinking and emotions, in conjunction with perceptions about patients' health trajectories. Main Outcome Measure Enactment of an LOI order after entry into the cohort. Results During the 6 months of observation, 14 patients (42.4%) had an LOI order enacted. In adjusted analyses, higher levels of parental hopeful patterns of thinking were significantly associated with increased odds of enactment of an LOI order (adjusted odds ratio [AOR], 2.73; 95% confidence interval [CI], 1.04-7.22). Increased odds of LOI enactment were associated to nonsignificant degrees with lower levels of parental positive affect (AOR, 0.44; 95% CI, 0.17-1.12), higher levels of parental negative affect (AOR, 2.02; 95% CI, 0.98-4.16), and parental perceptions of worsening health over time (AOR, 1.72; 95% CI, 0.73-4.07). Conclusion For pediatric patients receiving palliative care consultative services, higher levels of parents' hopeful patterns of thinking are associated with subsequent enactment of LOI orders, suggesting that emotional and cognitive processes have a combined effect on medical decision making.

Objective To assess the prevalence and patterns of exposure to drugs and therapeutic agents among hospitalized pediatric patients. Design Retrospective cohort study. Setting A total of 411 general hospitals and 52 children's hospitals throughout the United States. Patients A total of 587 427 patients younger than 18 years, excluding healthy newborns, hospitalized in 2006, representing one-fifth of all pediatric admissions in the United States. Main Outcome Measures Daily and cumulative exposure to drugs and therapeutic agents. Results The most common exposures varied by patient age and by hospital type, with acetaminophen, albuterol, various antibiotics, fentanyl, heparin, ibuprofen, morphine, ondansetron, propofol, and ranitidine being among the most prevalent exposures. A considerable fraction of patients were exposed to numerous medications: in children's hospitals, on the first day of hospitalization, patients younger than 1 year at the 90th percentile of daily exposure to distinct medications received 11 drugs, and patients 1 year or older received 13 drugs; in general hospitals, 8 and 12 drugs, respectively. By hospital day 7, in children's hospitals, patients younger than 1 year at the 90th percentile of cumulative exposure to distinct distinct medications had received 29 drugs, and patients 1 year or older had received 35; in general hospitals, 22 and 28 drugs, respectively. Patients with less common conditions were more likely to be exposed to more drugs (P = .001). Conclusion A large fraction of hospitalized pediatric patients are exposed to substantial polypharmacy, especially patients with rare conditions.

Objective To compare women's acceptability ratings of 2 different intimate partner violence screening methods, an audiotape questionnaire and a written questionnaire, in a pediatric emergency department. Design Randomized clinical trial. Setting An urban, pediatric, tertiary care center emergency department. Participants Female caregivers of children. Main Exposure Intimate partner violence screening by either an audiotape or written questionnaire method. Main Outcome Measures Perceptions of each screening method's safety, acceptability, and ease of use. Results Fifty (10%) of 497 participants reported intimate partner violence, 30 (11%) of 266 in the audiotape group and 20 (9%) of 231 in the written questionnaire group ( P = .30). Women in the audiotape group were significantly more likely to report that the audiotape method did not put them at risk and was private. Women in both groups were satisfied with their screening method and were willing to use it again. Women in both groups preferred their given method over the idea of direct emergency department provider screening. Conclusions Screening for intimate partner violence with an audiotape method appears to have several advantages compared with screening by a written questionnaire, and the audiotape method may be associated with slightly higher rates of disclosing intimate partner violence. Trial Registration http://clinicaltrials.gov/show/NCT00122395

Objective To test the hypothesis that discharge disposition for adolescents admitted to medical hospitals after attempting suicide varies as a function of hospital type and geographic region. Design Retrospective cohort analysis. Setting The nationally representative Kids’ Inpatient Database for 2000. Participants Patients aged 10 to 19 years with a diagnosis of suicide attempt or self-inflicted injury. Main Outcome Measure Likelihood of transfer to another facility vs discharge to home. Results Care for 32 655 adolescents who attempted suicide was provided in adult hospitals (83% of hospitalizations), children’s units in general hospitals (10%), and children’s hospitals (4%). More than half (66%) of medical hospitalizations ended with discharge to home, 21% with transfer to a psychiatric, rehabilitation, or chronic care (P/R/C) facility, 10% with transfer to a skilled nursing facility, intermediate care facility, or short-term acute care hospital facility, and 2% with death or departure against medical advice. After adjustment for individual patient characteristics, children’s units were 44% more likely than adult hospitals to transfer adolescent patients to a P/R/C facility (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.07-1.94). Patients cared for outside the Northeast were significantly less likely to be transferred to a P/R/C facility (South: OR, 0.79; 95% CI, 0.65-0.97; Midwest: OR, 0.63; 95% CI, 0.49-0.80; West: OR, 0.29; 95% CI, 0.22-0.38). Conclusions Most adolescents admitted to a medical hospital after a suicide attempt are discharged to home, and the likelihood of transfer to another facility appears to be influenced by the geographic location of the admitting hospital and whether it caters to children.