Brian Pate, MD, FAAP

1. Uehara R, Yashiro M, Nakamura Y, Yanagawa H. Clinical features of patients with Kawasaki disease whose parents had the same disease. Arch Pediatr Adolesc Med. 2004;158:1166-9.

Authors from the Department of Public Heath, Jichi Medical School and Saitama Prefectural University in Japan note that in the 35 years that have passed since the initial descriptions of Kawasaki disease some patients who had the disease have reached reproductive age and, thus, familial cases of two generations occur. Based on responses to nationwide surveys of hospitals and pediatric departments 65 cases of Kawasaki disease were identified in children whose parents had the same diagnosis. The odds for having sibling cases of Kawasaki disease were significantly increased for patients whose parents had the disease (OR, 6.94; 95% CI, 2.77–17.38). Patients with parental Kawasaki disease were also more likely to have recurrent disease, receive additional intravenous immunoglobulin administrations, and to have coronary artery abnormalities. The authors aptly discuss significant limitations to the study design; however, they conclude that these results highlight the need for exploration of a possible genetic contribution to pathogenesis of Kawasaki disease.

2. Jacobs RF, Maples HD, Aranda JV, et al. Pharmacokinetics of intravenously administered azithromycin in pediatric patients. Pediatr Infect Dis J. 2005;24:34-9.

Azithromyin is an azalide antibiotic with in vitro activity against a spectrum of bacterial pathogens commonly treated in pediatric infections. Currently intravenous (IV) azithromycin is only approved for use in adults. These researchers from three sites of the Pediatric Pharmacology Research Unit Network report results of an open-label single-dose pharmacokinetic and tolerance study of intravenous azithromycin in a pediatric population. This information will be required to facilitate approval for use in the pediatric population, as well as guide dosing for therapeutic trials. The authors studied pharmacokinetics in 29 patients ages 0.5 to &lte;16 years of age and conclude that the disposition of IV administered azithromycin is comparable in patients in this age range; however, there was a tendency for increased clearance in younger children. The most common adverse effect was nausea that did not require intervention reported in 25% of the subjects.

3. Berger WE, Qaqundah PY, Blake, K, et al. Safety of budesonide inhalation suspension in infants aged six to twelve months with mild to moderate persistent asthma or recurrent wheeze. J Pediatr. 2005;146:91-5.

Current guidelines recommend inhaled corticosteroids (ICS) for long-term management of persistent asthma in children regardless of age. Currently the only nebulized ICS approved for use by the US Food and Drug Administration is budesonide. Controlled studies analyzing the safety and efficacy of budesonide exclusively in infants is lacking. Therefore, these researchers present a multicenter, randomized, double-blinded, parallel group, placebo-controlled study of 141 patients assessing the safety of once-daily administered nebulized budesonide in infants with persistent asthma. The primary outcome variable was adrenal function measured as mean changes from baseline to study end in postcosyntropin-stimulated plasma cortisol levels. The study was not powered to measure efficacy. The study concludes that the safety profile for nebulized budesonide was similar to that of placebo, with no suppression of adrenal function.

1. Uehara R, Yashiro M, Nakamura Y, Yanagawa H. Clinical features of patients with Kawasaki disease whose parents had the same disease. Arch Pediatr Adolesc Med. 2004;158:1166-9.

Authors from the Department of Public Heath, Jichi Medical School and Saitama Prefectural University in Japan note that in the 35 years that have passed since the initial descriptions of Kawasaki disease some patients who had the disease have reached reproductive age and, thus, familial cases of two generations occur. Based on responses to nationwide surveys of hospitals and pediatric departments 65 cases of Kawasaki disease were identified in children whose parents had the same diagnosis. The odds for having sibling cases of Kawasaki disease were significantly increased for patients whose parents had the disease (OR, 6.94; 95% CI, 2.77–17.38). Patients with parental Kawasaki disease were also more likely to have recurrent disease, receive additional intravenous immunoglobulin administrations, and to have coronary artery abnormalities. The authors aptly discuss significant limitations to the study design; however, they conclude that these results highlight the need for exploration of a possible genetic contribution to pathogenesis of Kawasaki disease.

2. Jacobs RF, Maples HD, Aranda JV, et al. Pharmacokinetics of intravenously administered azithromycin in pediatric patients. Pediatr Infect Dis J. 2005;24:34-9.

Azithromyin is an azalide antibiotic with in vitro activity against a spectrum of bacterial pathogens commonly treated in pediatric infections. Currently intravenous (IV) azithromycin is only approved for use in adults. These researchers from three sites of the Pediatric Pharmacology Research Unit Network report results of an open-label single-dose pharmacokinetic and tolerance study of intravenous azithromycin in a pediatric population. This information will be required to facilitate approval for use in the pediatric population, as well as guide dosing for therapeutic trials. The authors studied pharmacokinetics in 29 patients ages 0.5 to &lte;16 years of age and conclude that the disposition of IV administered azithromycin is comparable in patients in this age range; however, there was a tendency for increased clearance in younger children. The most common adverse effect was nausea that did not require intervention reported in 25% of the subjects.

3. Berger WE, Qaqundah PY, Blake, K, et al. Safety of budesonide inhalation suspension in infants aged six to twelve months with mild to moderate persistent asthma or recurrent wheeze. J Pediatr. 2005;146:91-5.

Current guidelines recommend inhaled corticosteroids (ICS) for long-term management of persistent asthma in children regardless of age. Currently the only nebulized ICS approved for use by the US Food and Drug Administration is budesonide. Controlled studies analyzing the safety and efficacy of budesonide exclusively in infants is lacking. Therefore, these researchers present a multicenter, randomized, double-blinded, parallel group, placebo-controlled study of 141 patients assessing the safety of once-daily administered nebulized budesonide in infants with persistent asthma. The primary outcome variable was adrenal function measured as mean changes from baseline to study end in postcosyntropin-stimulated plasma cortisol levels. The study was not powered to measure efficacy. The study concludes that the safety profile for nebulized budesonide was similar to that of placebo, with no suppression of adrenal function.

1. Uehara R, Yashiro M, Nakamura Y, Yanagawa H. Clinical features of patients with Kawasaki disease whose parents had the same disease. Arch Pediatr Adolesc Med. 2004;158:1166-9.

Authors from the Department of Public Heath, Jichi Medical School and Saitama Prefectural University in Japan note that in the 35 years that have passed since the initial descriptions of Kawasaki disease some patients who had the disease have reached reproductive age and, thus, familial cases of two generations occur. Based on responses to nationwide surveys of hospitals and pediatric departments 65 cases of Kawasaki disease were identified in children whose parents had the same diagnosis. The odds for having sibling cases of Kawasaki disease were significantly increased for patients whose parents had the disease (OR, 6.94; 95% CI, 2.77–17.38). Patients with parental Kawasaki disease were also more likely to have recurrent disease, receive additional intravenous immunoglobulin administrations, and to have coronary artery abnormalities. The authors aptly discuss significant limitations to the study design; however, they conclude that these results highlight the need for exploration of a possible genetic contribution to pathogenesis of Kawasaki disease.

2. Jacobs RF, Maples HD, Aranda JV, et al. Pharmacokinetics of intravenously administered azithromycin in pediatric patients. Pediatr Infect Dis J. 2005;24:34-9.

Azithromyin is an azalide antibiotic with in vitro activity against a spectrum of bacterial pathogens commonly treated in pediatric infections. Currently intravenous (IV) azithromycin is only approved for use in adults. These researchers from three sites of the Pediatric Pharmacology Research Unit Network report results of an open-label single-dose pharmacokinetic and tolerance study of intravenous azithromycin in a pediatric population. This information will be required to facilitate approval for use in the pediatric population, as well as guide dosing for therapeutic trials. The authors studied pharmacokinetics in 29 patients ages 0.5 to &lte;16 years of age and conclude that the disposition of IV administered azithromycin is comparable in patients in this age range; however, there was a tendency for increased clearance in younger children. The most common adverse effect was nausea that did not require intervention reported in 25% of the subjects.

3. Berger WE, Qaqundah PY, Blake, K, et al. Safety of budesonide inhalation suspension in infants aged six to twelve months with mild to moderate persistent asthma or recurrent wheeze. J Pediatr. 2005;146:91-5.

Current guidelines recommend inhaled corticosteroids (ICS) for long-term management of persistent asthma in children regardless of age. Currently the only nebulized ICS approved for use by the US Food and Drug Administration is budesonide. Controlled studies analyzing the safety and efficacy of budesonide exclusively in infants is lacking. Therefore, these researchers present a multicenter, randomized, double-blinded, parallel group, placebo-controlled study of 141 patients assessing the safety of once-daily administered nebulized budesonide in infants with persistent asthma. The primary outcome variable was adrenal function measured as mean changes from baseline to study end in postcosyntropin-stimulated plasma cortisol levels. The study was not powered to measure efficacy. The study concludes that the safety profile for nebulized budesonide was similar to that of placebo, with no suppression of adrenal function.

Parents' Priorities and Satisfaction with Acute Pediatric Care

Ammentorp J, Mainz J, Sabroe S. Parents’ priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med. 2005;159:127-31.

Researchers from Kolding Hospital in Denmark designed this study to identify parents’ priorities of and satisfaction with care provided to pediatric patients by nurses and physicians. The cross-sectional study took place on the pediatric ward by enrolling consecutively admitted patients between 0800 and 2200 who spoke and understood Danish. The researchers designed and validated a 36 item questionnaire with input from 13 previous studies about patient satisfaction. The items were assessed using a 5-point Likert scale and were grouped into six dimensions of service: 1) Access to care and treatment, 2) Information and communication related to care and treatment, 3) Information related to practical conditions (i.e., orientation to the ward), 4) Physicians’ behavior, 5) Nurses’ behavior, and 6) Access to service. The survey consisted of two parts. Section 1 addressed priorities and was to be filled out by the parent(s) at admission. Section 2 addressed satisfaction and was to be filled out at discharge. The response rates for Section 1 and Section 2 were 84% and 67%, respectively. Statistical analysis demonstrated that parents could differentiate between priority and satisfaction.

Parents generally rated most aspects of care as important, and aspects related directly to treatment were rated highest. The three most important priorities with the assigned scores with 5 being the highest possible score were: 1) Find(ing) out what is wrong with the child (4.6), 2) Taking care of the child’s pain if it is relevant (4.6), and 3) Explanation of the diagnosis/problem (4.5). The least important items for parents in general were related to orientation of the ward. Interestingly, the least important item for parents in the study was having the child discharged the same day as admission (2.7).

Parents were most satisfied with the kindness of the nurses (4.4) and understanding the nurses information (4.3). The lowest satisfaction level was found with waiting time on the ward for medication evaluation, and this was also the greatest gap between priority and satisfaction for the parents in the study (priority 4.5, satisfaction 3.0)

The researchers present satisfaction and priority data together in a scatter plot with priority mean score on the vertical axis and satisfaction mean score on the horizontal access and in so doing create four quadrants that aid in focusing attention on improving quality on their ward. The researchers conclude that items that plot in the upper left quadrant deserve special attention as items that parents believe are important but are not satisfied with. Items differentiating between physician and nursing involvement in the same service areas were plotted as well, and results indicated that, in general, parents gave physician service higher priority but were more satisfied with nursing service.

The researchers conclude that the tool they describe is a validated questionnaire that can be used to evaluate parent priorities for and satisfaction with care provided on pediatric inpatient wards. This information can be used to guide further investigations and quality development. For the study ward this tool demonstrated that waiting time and communication with parents represented the most important areas for improvement.

Satisfaction is an important aspect of quality of care, as well an important attribute of the potential value added by physicians dedicated to inpatient medicine. Several important factors limit generalizing the specific conclusions of this study, including not including the non-Danish speaking minority and not identifying parents whose children have had multiple inpatient admissions. Regardless, the survey and scatter plot analysis with a “special attention” quadrant have obvious utility in the effort to produce quality improvement with regard to parents’ perception of the quality of care their children receive. Other interesting applications not specifically addressed in the study include measuring the priorities and satisfaction level of patients old enough to respond, including questions regarding service provided by nurse practitioners or physician’s assistants and testing to see if parents’ and/or patients’ priorities change from admission, through hospitalization, and at discharge.

Evaluation of a Staff-Only Hospitalist System in a Tertiary Care, Academic Children's Hospital

Dwight P, MacArthur C, Friedman JN, et al. Evaluation of a staff-only hospitalist system in a tertiary care, academic children’s hospital. Pediatrics. 2004;114:1545-9.

The division of pediatrics at The Hospital for Sick Children in Toronto, a tertiary care, academic center, operates a pediatric inpatient unit with approximately 4000 admissions each year. In 1995, limited resident duty hours led to a reorganization of inpatient pediatric teams to include two distinct hospitalist models: A hospitalist/housestaff model (CTU) and hospitalist staff -only model (CPU). The authors review recent research that has demonstrated the efficiency of hospitalist/housestaff systems in both adult and pediatric medicine and accurately point out that published data is lacking assessing the staff -only pediatric hospitalist model. Therefore, the authors designed a cohort study of 3807 admissions to the general inpatient pediatric unit between July 1, 1996 and June 30, 1997.

The primary outcome measure was length of stay, and secondary outcome measures included frequency of subspecialty consultation, readmission to the hospital, and death. Consultations were measured as none or >1 and readmissions were defined as admission within 7 days of discharge for the same or a related diagnosis. Clinically relevant information collected for each patient included age, gender, referral source, stay in a special care unit, most responsible diagnosis, and comorbidity. Comorbidity was defined as either an uncomplicated stay or a stay complicated by a chronic illness, series or important conditions, and/or a potentially life-threatening condition. The CTU team had a daily census of 24 to 30 patients and consisted of 1 attending pediatrician, 3 or 4 pediatric residents, and 2 medical students. CTU pediatricians attended this service 4–8 weeks each year. The CPU was staffed with 3 pediatricians who were responsible for all aspects of care Monday through Friday from 0800 to 1700 and on weekends. Medical students were included on this team. Overnight and weekends clinical fellows not part of the CPU team provided coverage. Each CPU physicians maintained a daily census of 8–10 patients. These physicians spent approximately 11 months of the year providing inpatient care.

During the study there were 3807 admissions, of which 33% were to the CPU and 67% were to the CTU. Patients admitted to the CPU were older (median age: 95 weeks vs. 69 weeks, p < .01) and less likely to have comorbidity (24% vs. 30%; p < .01). The diagnoses admitted to the two teams were not significantly different. The median length of hospital stay for the CPU team was 2.5 days (interquartile range [IQR]: 1.6–4.4 days) versus 2.9 days (IQR: 1.8–4.9) for the CTU team (p < .01). Multivariate linear regression showed a significant difference in length of stay after adjustment for age, gender and comorbidity (p < .04). The authors performed a stratified analysis of the 10 most frequent diagnoses admitted during the study period, and the median length of stay for these groups combined was shorter on the CPU team compared with the CTU team (2.1 days vs. 2.6 days, p < .01). There was no significant difference between the two teams with readmissions, frequency of consultation, or death.

The authors discuss some important limitations to the study. First, the unique characteristics of the individual unit studied inhibit the ability to generalize the results. Second, there were some differences in the baseline characteristics between the two groups, although multivariate analysis of theses differences did not change the statistical significance of the results. Finally, satisfaction of patients, families, and care providers was not measured.

These researchers conclude that within this system the hospitalist staff -only team reduced the length of stay by 14% compared with an attending staff/housestaff team. Although statistically significant, the clinical significance of this reduction in length of stay is unclear and the authors did not include financial data in the study design. Despite these facts, the authors make an important assertion that the difference in stay of 8 hours may be enough to promote throughput by decreasing wait times for admissions from the emergency departments and/or special care units. Additional studies are required to test this assertion.

Parents' Priorities and Satisfaction with Acute Pediatric Care

Ammentorp J, Mainz J, Sabroe S. Parents’ priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med. 2005;159:127-31.

Researchers from Kolding Hospital in Denmark designed this study to identify parents’ priorities of and satisfaction with care provided to pediatric patients by nurses and physicians. The cross-sectional study took place on the pediatric ward by enrolling consecutively admitted patients between 0800 and 2200 who spoke and understood Danish. The researchers designed and validated a 36 item questionnaire with input from 13 previous studies about patient satisfaction. The items were assessed using a 5-point Likert scale and were grouped into six dimensions of service: 1) Access to care and treatment, 2) Information and communication related to care and treatment, 3) Information related to practical conditions (i.e., orientation to the ward), 4) Physicians’ behavior, 5) Nurses’ behavior, and 6) Access to service. The survey consisted of two parts. Section 1 addressed priorities and was to be filled out by the parent(s) at admission. Section 2 addressed satisfaction and was to be filled out at discharge. The response rates for Section 1 and Section 2 were 84% and 67%, respectively. Statistical analysis demonstrated that parents could differentiate between priority and satisfaction.

Parents generally rated most aspects of care as important, and aspects related directly to treatment were rated highest. The three most important priorities with the assigned scores with 5 being the highest possible score were: 1) Find(ing) out what is wrong with the child (4.6), 2) Taking care of the child’s pain if it is relevant (4.6), and 3) Explanation of the diagnosis/problem (4.5). The least important items for parents in general were related to orientation of the ward. Interestingly, the least important item for parents in the study was having the child discharged the same day as admission (2.7).

Parents were most satisfied with the kindness of the nurses (4.4) and understanding the nurses information (4.3). The lowest satisfaction level was found with waiting time on the ward for medication evaluation, and this was also the greatest gap between priority and satisfaction for the parents in the study (priority 4.5, satisfaction 3.0)

The researchers present satisfaction and priority data together in a scatter plot with priority mean score on the vertical axis and satisfaction mean score on the horizontal access and in so doing create four quadrants that aid in focusing attention on improving quality on their ward. The researchers conclude that items that plot in the upper left quadrant deserve special attention as items that parents believe are important but are not satisfied with. Items differentiating between physician and nursing involvement in the same service areas were plotted as well, and results indicated that, in general, parents gave physician service higher priority but were more satisfied with nursing service.

The researchers conclude that the tool they describe is a validated questionnaire that can be used to evaluate parent priorities for and satisfaction with care provided on pediatric inpatient wards. This information can be used to guide further investigations and quality development. For the study ward this tool demonstrated that waiting time and communication with parents represented the most important areas for improvement.

Satisfaction is an important aspect of quality of care, as well an important attribute of the potential value added by physicians dedicated to inpatient medicine. Several important factors limit generalizing the specific conclusions of this study, including not including the non-Danish speaking minority and not identifying parents whose children have had multiple inpatient admissions. Regardless, the survey and scatter plot analysis with a “special attention” quadrant have obvious utility in the effort to produce quality improvement with regard to parents’ perception of the quality of care their children receive. Other interesting applications not specifically addressed in the study include measuring the priorities and satisfaction level of patients old enough to respond, including questions regarding service provided by nurse practitioners or physician’s assistants and testing to see if parents’ and/or patients’ priorities change from admission, through hospitalization, and at discharge.

Evaluation of a Staff-Only Hospitalist System in a Tertiary Care, Academic Children's Hospital

Dwight P, MacArthur C, Friedman JN, et al. Evaluation of a staff-only hospitalist system in a tertiary care, academic children’s hospital. Pediatrics. 2004;114:1545-9.

The division of pediatrics at The Hospital for Sick Children in Toronto, a tertiary care, academic center, operates a pediatric inpatient unit with approximately 4000 admissions each year. In 1995, limited resident duty hours led to a reorganization of inpatient pediatric teams to include two distinct hospitalist models: A hospitalist/housestaff model (CTU) and hospitalist staff -only model (CPU). The authors review recent research that has demonstrated the efficiency of hospitalist/housestaff systems in both adult and pediatric medicine and accurately point out that published data is lacking assessing the staff -only pediatric hospitalist model. Therefore, the authors designed a cohort study of 3807 admissions to the general inpatient pediatric unit between July 1, 1996 and June 30, 1997.

The primary outcome measure was length of stay, and secondary outcome measures included frequency of subspecialty consultation, readmission to the hospital, and death. Consultations were measured as none or >1 and readmissions were defined as admission within 7 days of discharge for the same or a related diagnosis. Clinically relevant information collected for each patient included age, gender, referral source, stay in a special care unit, most responsible diagnosis, and comorbidity. Comorbidity was defined as either an uncomplicated stay or a stay complicated by a chronic illness, series or important conditions, and/or a potentially life-threatening condition. The CTU team had a daily census of 24 to 30 patients and consisted of 1 attending pediatrician, 3 or 4 pediatric residents, and 2 medical students. CTU pediatricians attended this service 4–8 weeks each year. The CPU was staffed with 3 pediatricians who were responsible for all aspects of care Monday through Friday from 0800 to 1700 and on weekends. Medical students were included on this team. Overnight and weekends clinical fellows not part of the CPU team provided coverage. Each CPU physicians maintained a daily census of 8–10 patients. These physicians spent approximately 11 months of the year providing inpatient care.

During the study there were 3807 admissions, of which 33% were to the CPU and 67% were to the CTU. Patients admitted to the CPU were older (median age: 95 weeks vs. 69 weeks, p < .01) and less likely to have comorbidity (24% vs. 30%; p < .01). The diagnoses admitted to the two teams were not significantly different. The median length of hospital stay for the CPU team was 2.5 days (interquartile range [IQR]: 1.6–4.4 days) versus 2.9 days (IQR: 1.8–4.9) for the CTU team (p < .01). Multivariate linear regression showed a significant difference in length of stay after adjustment for age, gender and comorbidity (p < .04). The authors performed a stratified analysis of the 10 most frequent diagnoses admitted during the study period, and the median length of stay for these groups combined was shorter on the CPU team compared with the CTU team (2.1 days vs. 2.6 days, p < .01). There was no significant difference between the two teams with readmissions, frequency of consultation, or death.

The authors discuss some important limitations to the study. First, the unique characteristics of the individual unit studied inhibit the ability to generalize the results. Second, there were some differences in the baseline characteristics between the two groups, although multivariate analysis of theses differences did not change the statistical significance of the results. Finally, satisfaction of patients, families, and care providers was not measured.

These researchers conclude that within this system the hospitalist staff -only team reduced the length of stay by 14% compared with an attending staff/housestaff team. Although statistically significant, the clinical significance of this reduction in length of stay is unclear and the authors did not include financial data in the study design. Despite these facts, the authors make an important assertion that the difference in stay of 8 hours may be enough to promote throughput by decreasing wait times for admissions from the emergency departments and/or special care units. Additional studies are required to test this assertion.

Parents' Priorities and Satisfaction with Acute Pediatric Care

Ammentorp J, Mainz J, Sabroe S. Parents’ priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med. 2005;159:127-31.

Researchers from Kolding Hospital in Denmark designed this study to identify parents’ priorities of and satisfaction with care provided to pediatric patients by nurses and physicians. The cross-sectional study took place on the pediatric ward by enrolling consecutively admitted patients between 0800 and 2200 who spoke and understood Danish. The researchers designed and validated a 36 item questionnaire with input from 13 previous studies about patient satisfaction. The items were assessed using a 5-point Likert scale and were grouped into six dimensions of service: 1) Access to care and treatment, 2) Information and communication related to care and treatment, 3) Information related to practical conditions (i.e., orientation to the ward), 4) Physicians’ behavior, 5) Nurses’ behavior, and 6) Access to service. The survey consisted of two parts. Section 1 addressed priorities and was to be filled out by the parent(s) at admission. Section 2 addressed satisfaction and was to be filled out at discharge. The response rates for Section 1 and Section 2 were 84% and 67%, respectively. Statistical analysis demonstrated that parents could differentiate between priority and satisfaction.

Parents generally rated most aspects of care as important, and aspects related directly to treatment were rated highest. The three most important priorities with the assigned scores with 5 being the highest possible score were: 1) Find(ing) out what is wrong with the child (4.6), 2) Taking care of the child’s pain if it is relevant (4.6), and 3) Explanation of the diagnosis/problem (4.5). The least important items for parents in general were related to orientation of the ward. Interestingly, the least important item for parents in the study was having the child discharged the same day as admission (2.7).

Parents were most satisfied with the kindness of the nurses (4.4) and understanding the nurses information (4.3). The lowest satisfaction level was found with waiting time on the ward for medication evaluation, and this was also the greatest gap between priority and satisfaction for the parents in the study (priority 4.5, satisfaction 3.0)

The researchers present satisfaction and priority data together in a scatter plot with priority mean score on the vertical axis and satisfaction mean score on the horizontal access and in so doing create four quadrants that aid in focusing attention on improving quality on their ward. The researchers conclude that items that plot in the upper left quadrant deserve special attention as items that parents believe are important but are not satisfied with. Items differentiating between physician and nursing involvement in the same service areas were plotted as well, and results indicated that, in general, parents gave physician service higher priority but were more satisfied with nursing service.

The researchers conclude that the tool they describe is a validated questionnaire that can be used to evaluate parent priorities for and satisfaction with care provided on pediatric inpatient wards. This information can be used to guide further investigations and quality development. For the study ward this tool demonstrated that waiting time and communication with parents represented the most important areas for improvement.

Satisfaction is an important aspect of quality of care, as well an important attribute of the potential value added by physicians dedicated to inpatient medicine. Several important factors limit generalizing the specific conclusions of this study, including not including the non-Danish speaking minority and not identifying parents whose children have had multiple inpatient admissions. Regardless, the survey and scatter plot analysis with a “special attention” quadrant have obvious utility in the effort to produce quality improvement with regard to parents’ perception of the quality of care their children receive. Other interesting applications not specifically addressed in the study include measuring the priorities and satisfaction level of patients old enough to respond, including questions regarding service provided by nurse practitioners or physician’s assistants and testing to see if parents’ and/or patients’ priorities change from admission, through hospitalization, and at discharge.

Evaluation of a Staff-Only Hospitalist System in a Tertiary Care, Academic Children's Hospital

Dwight P, MacArthur C, Friedman JN, et al. Evaluation of a staff-only hospitalist system in a tertiary care, academic children’s hospital. Pediatrics. 2004;114:1545-9.

The division of pediatrics at The Hospital for Sick Children in Toronto, a tertiary care, academic center, operates a pediatric inpatient unit with approximately 4000 admissions each year. In 1995, limited resident duty hours led to a reorganization of inpatient pediatric teams to include two distinct hospitalist models: A hospitalist/housestaff model (CTU) and hospitalist staff -only model (CPU). The authors review recent research that has demonstrated the efficiency of hospitalist/housestaff systems in both adult and pediatric medicine and accurately point out that published data is lacking assessing the staff -only pediatric hospitalist model. Therefore, the authors designed a cohort study of 3807 admissions to the general inpatient pediatric unit between July 1, 1996 and June 30, 1997.

The primary outcome measure was length of stay, and secondary outcome measures included frequency of subspecialty consultation, readmission to the hospital, and death. Consultations were measured as none or >1 and readmissions were defined as admission within 7 days of discharge for the same or a related diagnosis. Clinically relevant information collected for each patient included age, gender, referral source, stay in a special care unit, most responsible diagnosis, and comorbidity. Comorbidity was defined as either an uncomplicated stay or a stay complicated by a chronic illness, series or important conditions, and/or a potentially life-threatening condition. The CTU team had a daily census of 24 to 30 patients and consisted of 1 attending pediatrician, 3 or 4 pediatric residents, and 2 medical students. CTU pediatricians attended this service 4–8 weeks each year. The CPU was staffed with 3 pediatricians who were responsible for all aspects of care Monday through Friday from 0800 to 1700 and on weekends. Medical students were included on this team. Overnight and weekends clinical fellows not part of the CPU team provided coverage. Each CPU physicians maintained a daily census of 8–10 patients. These physicians spent approximately 11 months of the year providing inpatient care.

During the study there were 3807 admissions, of which 33% were to the CPU and 67% were to the CTU. Patients admitted to the CPU were older (median age: 95 weeks vs. 69 weeks, p < .01) and less likely to have comorbidity (24% vs. 30%; p < .01). The diagnoses admitted to the two teams were not significantly different. The median length of hospital stay for the CPU team was 2.5 days (interquartile range [IQR]: 1.6–4.4 days) versus 2.9 days (IQR: 1.8–4.9) for the CTU team (p < .01). Multivariate linear regression showed a significant difference in length of stay after adjustment for age, gender and comorbidity (p < .04). The authors performed a stratified analysis of the 10 most frequent diagnoses admitted during the study period, and the median length of stay for these groups combined was shorter on the CPU team compared with the CTU team (2.1 days vs. 2.6 days, p < .01). There was no significant difference between the two teams with readmissions, frequency of consultation, or death.

The authors discuss some important limitations to the study. First, the unique characteristics of the individual unit studied inhibit the ability to generalize the results. Second, there were some differences in the baseline characteristics between the two groups, although multivariate analysis of theses differences did not change the statistical significance of the results. Finally, satisfaction of patients, families, and care providers was not measured.

These researchers conclude that within this system the hospitalist staff -only team reduced the length of stay by 14% compared with an attending staff/housestaff team. Although statistically significant, the clinical significance of this reduction in length of stay is unclear and the authors did not include financial data in the study design. Despite these facts, the authors make an important assertion that the difference in stay of 8 hours may be enough to promote throughput by decreasing wait times for admissions from the emergency departments and/or special care units. Additional studies are required to test this assertion.