Mark Shen, MD, SFHM

Clinical question: What is the impact of a peer benchmarking network on resource utilization in acute bronchiolitis?

Background: Acute bronchiolitis is the most common illness requiring hospitalization in children. Despite the publication of national evidence-based guidelines, variation and overuse of common therapies remains. Despite one report of successful implementation of evidence-based guidelines in a collaborative of freestanding children’s hospitals, most children are hospitalized outside of such institutions, and large-scale, lower-resource efforts have not been described.

Study design: Voluntary, quality-improvement (QI), and benchmarking collaborative.

Setting: Seventeen hospitals, including both community and freestanding children’s facilities.

Synopsis: Over a four-year period, data on 11,568 bronchiolitis hospitalizations were collected. The collaborative facilitated sharing of resources (e.g. scoring tools, guidelines), celebrated high performers on an annual basis, and encouraged regular data collection, primarily via conference calls and email. Notably, a common bundle of interventions were not used; groups worked on local improvement cycles, with only a few groups forming a small subcollaborative utilizing a shared pathway. A significant decrease in bronchodilator utilization and chest physiotherapy was seen over the course of the collaborative, although no change in chest radiography, steroid utilization, and RSV testing was noted.

This voluntary and low-resource effort by similarly motivated peers across a variety of inpatient settings demonstrated improvement over time. It is particularly notable as inpatient collaboratives with face-to-face meeting requirements, and annual fees, become more commonplace.

Study limitations include the lack of a conceptual model for studying contextual factors that might have led to improvement in the varied settings and secular changes over this time period. Additionally, EDs were not included in this initiative, which likely accounted for the lack of improvement in chest radiography and RSV testing. Nonetheless, scalable innovations such as this will become increasingly important as hospitalists search for value in health care.

Bottom line: Creating a national community of practice may reduce overutilization in bronchiolitis.

Citation: Ralston S, Garber M, Narang S, et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the Value in Inpatient Pediatrics Network. J Hosp Med. 2013;8(1):25-30.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the impact of a peer benchmarking network on resource utilization in acute bronchiolitis?

Background: Acute bronchiolitis is the most common illness requiring hospitalization in children. Despite the publication of national evidence-based guidelines, variation and overuse of common therapies remains. Despite one report of successful implementation of evidence-based guidelines in a collaborative of freestanding children’s hospitals, most children are hospitalized outside of such institutions, and large-scale, lower-resource efforts have not been described.

Study design: Voluntary, quality-improvement (QI), and benchmarking collaborative.

Setting: Seventeen hospitals, including both community and freestanding children’s facilities.

Synopsis: Over a four-year period, data on 11,568 bronchiolitis hospitalizations were collected. The collaborative facilitated sharing of resources (e.g. scoring tools, guidelines), celebrated high performers on an annual basis, and encouraged regular data collection, primarily via conference calls and email. Notably, a common bundle of interventions were not used; groups worked on local improvement cycles, with only a few groups forming a small subcollaborative utilizing a shared pathway. A significant decrease in bronchodilator utilization and chest physiotherapy was seen over the course of the collaborative, although no change in chest radiography, steroid utilization, and RSV testing was noted.

This voluntary and low-resource effort by similarly motivated peers across a variety of inpatient settings demonstrated improvement over time. It is particularly notable as inpatient collaboratives with face-to-face meeting requirements, and annual fees, become more commonplace.

Study limitations include the lack of a conceptual model for studying contextual factors that might have led to improvement in the varied settings and secular changes over this time period. Additionally, EDs were not included in this initiative, which likely accounted for the lack of improvement in chest radiography and RSV testing. Nonetheless, scalable innovations such as this will become increasingly important as hospitalists search for value in health care.

Bottom line: Creating a national community of practice may reduce overutilization in bronchiolitis.

Citation: Ralston S, Garber M, Narang S, et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the Value in Inpatient Pediatrics Network. J Hosp Med. 2013;8(1):25-30.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the impact of a peer benchmarking network on resource utilization in acute bronchiolitis?

Background: Acute bronchiolitis is the most common illness requiring hospitalization in children. Despite the publication of national evidence-based guidelines, variation and overuse of common therapies remains. Despite one report of successful implementation of evidence-based guidelines in a collaborative of freestanding children’s hospitals, most children are hospitalized outside of such institutions, and large-scale, lower-resource efforts have not been described.

Study design: Voluntary, quality-improvement (QI), and benchmarking collaborative.

Setting: Seventeen hospitals, including both community and freestanding children’s facilities.

Synopsis: Over a four-year period, data on 11,568 bronchiolitis hospitalizations were collected. The collaborative facilitated sharing of resources (e.g. scoring tools, guidelines), celebrated high performers on an annual basis, and encouraged regular data collection, primarily via conference calls and email. Notably, a common bundle of interventions were not used; groups worked on local improvement cycles, with only a few groups forming a small subcollaborative utilizing a shared pathway. A significant decrease in bronchodilator utilization and chest physiotherapy was seen over the course of the collaborative, although no change in chest radiography, steroid utilization, and RSV testing was noted.

This voluntary and low-resource effort by similarly motivated peers across a variety of inpatient settings demonstrated improvement over time. It is particularly notable as inpatient collaboratives with face-to-face meeting requirements, and annual fees, become more commonplace.

Study limitations include the lack of a conceptual model for studying contextual factors that might have led to improvement in the varied settings and secular changes over this time period. Additionally, EDs were not included in this initiative, which likely accounted for the lack of improvement in chest radiography and RSV testing. Nonetheless, scalable innovations such as this will become increasingly important as hospitalists search for value in health care.

Bottom line: Creating a national community of practice may reduce overutilization in bronchiolitis.

Citation: Ralston S, Garber M, Narang S, et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the Value in Inpatient Pediatrics Network. J Hosp Med. 2013;8(1):25-30.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Dear Mark,

I am pleased and excited that you are willing to abandon your plan for being a vagabond and will give serious consideration to joining the faculty of the Department of Pediatrics to become a core member of a new [general pediatric inpatient] program that I believe has exciting potential.

So reads the first line of my very first job offer letter. Obviously, my chairman had a sense of humor. But he also was not off target, as before May 21 of my third year of residency, I had no meaningful work lined up. Dreams of locum tenens work in Hawaii or a California coastal town quickly disappeared as I received only offers for work in small-town Mississippi and Oklahoma. Eleven years later, I don’t think I could have planned a more fulfilling early career, particularly when the alternative might have been surfing on the Mississippi River.

I would like this opportunity, in my final column as The Hospitalist’s pediatric editor, to reflect on this odyssey from vagabond to hospitalist.

The Early Years

As a new attending, I was appropriately terrified of how much I didn’t know. I also had ambitious goals at first, wanting to emulate my two favorite role models from residency, Charles Ginsburg and Heinz Eichenwald. We might call them hospitalists now, but back then they were old-fashioned, generalist inpatient clinician-educators, even while chairing the department of pediatrics over their separate tenures. They were the smartest and wisest teachers that I have ever met. These early years were a pseudo-fellowship of sorts; under their tutelage, I soaked up more than I ever had during residency.

Despite all of this learning, I remained sheltered in my clinician-educator bubble. The path to excellence for me was defined through frequent trips to the library (where journals used to be stored) and trying to teach as well as my mentors did. I largely was ignorant of the national hospitalist movement, until the 2007 SHM annual meeting was held in my backyard in Dallas. Listening to Bob Wachter that year, and then Don Berwick the following year, I suddenly realized the tremendous and intertwined importance of the quality movement and hospitalists. We were going to fix medicine. OK, maybe not all of medicine, but it happened to be the perfect time for me to learn about our health-care crisis, quality, and the role of hospital medicine.

If my first five years were about clinical medicine, the next five years were all about lessons in leadership. I had a new role, directing 8 15 20 25 hospitalists—and now was accountable for the group’s results. I’ve often said that an explicit leadership role is like stepping behind a curtain, where your own previous n=1 perspective is now the challenge of herding a group of n=25. And let’s be clear that it’s one thing to manage the group and keep the ship afloat, but it’s entirely another thing to lead the group toward success.

A Path for Me

Although the cacophony of managing that many voices was deafening early on, I found solace in the lessons of quality improvement (QI), where no project lives without a team that is all going the same direction. Between the national opportunities for collaborative improvement and the day-to-day experiences within my group, I found two simple principles worked well: 1) engage the team and 2) deliver objective results.

And just as I had craved a clinical learning environment early on, I now found myself learning from local and national peers putting their leadership skills in action to produce quality outcomes. The beauty of collaborative teamwork is that it creates self-sustaining capacity for more positive results.

Looking forward, the opportunities seem limitless for pediatric hospital medicine. From the inherent fulfillment of our day-to-day bedside work to the explicit leadership that we offer the complex hospital system, our family of pediatric hospitalists has blazed career paths in all directions. We are program directors. We are directors of quality and safety. We are division directors and section chiefs. We are professors. We are fellowship-trained. We are CEOs, of entire hospitals and the CMO of CMS. There has never been a better time to be a pediatric hospitalist.

This rapid ascent has to be the fastest in the history of medicine and might surprise the unsuspecting, but these career paths really should have been expected. Residents and students still identify the most with their ward months—we always will be leaders in education. Hospitals and health-care systems recognize the value of hospitalists as systems improvers and will forever need enlightened physicians to guide safer, better care. But we also remain generalists, perched over the exact intersection of acute illness and health. From this vantage point, we have the perfect perspective from which to lead the transformation of our health-care system. I’m not sure there is a leadership position in health care that a hospitalist will not fill in the near future.

A New Frontier

With all of this opportunity before us, there exists an imperative for true leadership. And unlike all of our past requirements for achievement, relying on our quantitative abilities will no longer be enough. Rather, we will need to focus on the qualitative “soft” skills, whether you call this emotional intelligence, interpersonal communication, or behavioral economics. The creation of value-based, care-delivery systems requires high-functioning units. We will need to design and lead teams from the bedside to the boardroom.

In the coming years, this leadership imperative will only intensify, as we all will be pressured to do more with less. We will be asked to improve quality and decrease costs. We will need to broaden our focus to health in addition to acute illness. Doing more with less will require courage and leadership. If you look at our growth curve to date, we have an abundance of both.

Dr. Shen is medical director of hospital medicine at Dell Children's Medical Center in Austin, Texas. He served as The Hospitalist's pediatric editor since 2010 and this marks his last column in his role as editor. In his newfound spare time, he looks forward to defining value in health care.

Dear Mark,

I am pleased and excited that you are willing to abandon your plan for being a vagabond and will give serious consideration to joining the faculty of the Department of Pediatrics to become a core member of a new [general pediatric inpatient] program that I believe has exciting potential.

So reads the first line of my very first job offer letter. Obviously, my chairman had a sense of humor. But he also was not off target, as before May 21 of my third year of residency, I had no meaningful work lined up. Dreams of locum tenens work in Hawaii or a California coastal town quickly disappeared as I received only offers for work in small-town Mississippi and Oklahoma. Eleven years later, I don’t think I could have planned a more fulfilling early career, particularly when the alternative might have been surfing on the Mississippi River.

I would like this opportunity, in my final column as The Hospitalist’s pediatric editor, to reflect on this odyssey from vagabond to hospitalist.

The Early Years

As a new attending, I was appropriately terrified of how much I didn’t know. I also had ambitious goals at first, wanting to emulate my two favorite role models from residency, Charles Ginsburg and Heinz Eichenwald. We might call them hospitalists now, but back then they were old-fashioned, generalist inpatient clinician-educators, even while chairing the department of pediatrics over their separate tenures. They were the smartest and wisest teachers that I have ever met. These early years were a pseudo-fellowship of sorts; under their tutelage, I soaked up more than I ever had during residency.

Despite all of this learning, I remained sheltered in my clinician-educator bubble. The path to excellence for me was defined through frequent trips to the library (where journals used to be stored) and trying to teach as well as my mentors did. I largely was ignorant of the national hospitalist movement, until the 2007 SHM annual meeting was held in my backyard in Dallas. Listening to Bob Wachter that year, and then Don Berwick the following year, I suddenly realized the tremendous and intertwined importance of the quality movement and hospitalists. We were going to fix medicine. OK, maybe not all of medicine, but it happened to be the perfect time for me to learn about our health-care crisis, quality, and the role of hospital medicine.

If my first five years were about clinical medicine, the next five years were all about lessons in leadership. I had a new role, directing 8 15 20 25 hospitalists—and now was accountable for the group’s results. I’ve often said that an explicit leadership role is like stepping behind a curtain, where your own previous n=1 perspective is now the challenge of herding a group of n=25. And let’s be clear that it’s one thing to manage the group and keep the ship afloat, but it’s entirely another thing to lead the group toward success.

A Path for Me

Although the cacophony of managing that many voices was deafening early on, I found solace in the lessons of quality improvement (QI), where no project lives without a team that is all going the same direction. Between the national opportunities for collaborative improvement and the day-to-day experiences within my group, I found two simple principles worked well: 1) engage the team and 2) deliver objective results.

And just as I had craved a clinical learning environment early on, I now found myself learning from local and national peers putting their leadership skills in action to produce quality outcomes. The beauty of collaborative teamwork is that it creates self-sustaining capacity for more positive results.

Looking forward, the opportunities seem limitless for pediatric hospital medicine. From the inherent fulfillment of our day-to-day bedside work to the explicit leadership that we offer the complex hospital system, our family of pediatric hospitalists has blazed career paths in all directions. We are program directors. We are directors of quality and safety. We are division directors and section chiefs. We are professors. We are fellowship-trained. We are CEOs, of entire hospitals and the CMO of CMS. There has never been a better time to be a pediatric hospitalist.

This rapid ascent has to be the fastest in the history of medicine and might surprise the unsuspecting, but these career paths really should have been expected. Residents and students still identify the most with their ward months—we always will be leaders in education. Hospitals and health-care systems recognize the value of hospitalists as systems improvers and will forever need enlightened physicians to guide safer, better care. But we also remain generalists, perched over the exact intersection of acute illness and health. From this vantage point, we have the perfect perspective from which to lead the transformation of our health-care system. I’m not sure there is a leadership position in health care that a hospitalist will not fill in the near future.

A New Frontier

With all of this opportunity before us, there exists an imperative for true leadership. And unlike all of our past requirements for achievement, relying on our quantitative abilities will no longer be enough. Rather, we will need to focus on the qualitative “soft” skills, whether you call this emotional intelligence, interpersonal communication, or behavioral economics. The creation of value-based, care-delivery systems requires high-functioning units. We will need to design and lead teams from the bedside to the boardroom.

In the coming years, this leadership imperative will only intensify, as we all will be pressured to do more with less. We will be asked to improve quality and decrease costs. We will need to broaden our focus to health in addition to acute illness. Doing more with less will require courage and leadership. If you look at our growth curve to date, we have an abundance of both.

Dr. Shen is medical director of hospital medicine at Dell Children's Medical Center in Austin, Texas. He served as The Hospitalist's pediatric editor since 2010 and this marks his last column in his role as editor. In his newfound spare time, he looks forward to defining value in health care.

Dear Mark,

I am pleased and excited that you are willing to abandon your plan for being a vagabond and will give serious consideration to joining the faculty of the Department of Pediatrics to become a core member of a new [general pediatric inpatient] program that I believe has exciting potential.

So reads the first line of my very first job offer letter. Obviously, my chairman had a sense of humor. But he also was not off target, as before May 21 of my third year of residency, I had no meaningful work lined up. Dreams of locum tenens work in Hawaii or a California coastal town quickly disappeared as I received only offers for work in small-town Mississippi and Oklahoma. Eleven years later, I don’t think I could have planned a more fulfilling early career, particularly when the alternative might have been surfing on the Mississippi River.

I would like this opportunity, in my final column as The Hospitalist’s pediatric editor, to reflect on this odyssey from vagabond to hospitalist.

The Early Years

As a new attending, I was appropriately terrified of how much I didn’t know. I also had ambitious goals at first, wanting to emulate my two favorite role models from residency, Charles Ginsburg and Heinz Eichenwald. We might call them hospitalists now, but back then they were old-fashioned, generalist inpatient clinician-educators, even while chairing the department of pediatrics over their separate tenures. They were the smartest and wisest teachers that I have ever met. These early years were a pseudo-fellowship of sorts; under their tutelage, I soaked up more than I ever had during residency.

Despite all of this learning, I remained sheltered in my clinician-educator bubble. The path to excellence for me was defined through frequent trips to the library (where journals used to be stored) and trying to teach as well as my mentors did. I largely was ignorant of the national hospitalist movement, until the 2007 SHM annual meeting was held in my backyard in Dallas. Listening to Bob Wachter that year, and then Don Berwick the following year, I suddenly realized the tremendous and intertwined importance of the quality movement and hospitalists. We were going to fix medicine. OK, maybe not all of medicine, but it happened to be the perfect time for me to learn about our health-care crisis, quality, and the role of hospital medicine.

If my first five years were about clinical medicine, the next five years were all about lessons in leadership. I had a new role, directing 8 15 20 25 hospitalists—and now was accountable for the group’s results. I’ve often said that an explicit leadership role is like stepping behind a curtain, where your own previous n=1 perspective is now the challenge of herding a group of n=25. And let’s be clear that it’s one thing to manage the group and keep the ship afloat, but it’s entirely another thing to lead the group toward success.

A Path for Me

Although the cacophony of managing that many voices was deafening early on, I found solace in the lessons of quality improvement (QI), where no project lives without a team that is all going the same direction. Between the national opportunities for collaborative improvement and the day-to-day experiences within my group, I found two simple principles worked well: 1) engage the team and 2) deliver objective results.

And just as I had craved a clinical learning environment early on, I now found myself learning from local and national peers putting their leadership skills in action to produce quality outcomes. The beauty of collaborative teamwork is that it creates self-sustaining capacity for more positive results.

Looking forward, the opportunities seem limitless for pediatric hospital medicine. From the inherent fulfillment of our day-to-day bedside work to the explicit leadership that we offer the complex hospital system, our family of pediatric hospitalists has blazed career paths in all directions. We are program directors. We are directors of quality and safety. We are division directors and section chiefs. We are professors. We are fellowship-trained. We are CEOs, of entire hospitals and the CMO of CMS. There has never been a better time to be a pediatric hospitalist.

This rapid ascent has to be the fastest in the history of medicine and might surprise the unsuspecting, but these career paths really should have been expected. Residents and students still identify the most with their ward months—we always will be leaders in education. Hospitals and health-care systems recognize the value of hospitalists as systems improvers and will forever need enlightened physicians to guide safer, better care. But we also remain generalists, perched over the exact intersection of acute illness and health. From this vantage point, we have the perfect perspective from which to lead the transformation of our health-care system. I’m not sure there is a leadership position in health care that a hospitalist will not fill in the near future.

A New Frontier

With all of this opportunity before us, there exists an imperative for true leadership. And unlike all of our past requirements for achievement, relying on our quantitative abilities will no longer be enough. Rather, we will need to focus on the qualitative “soft” skills, whether you call this emotional intelligence, interpersonal communication, or behavioral economics. The creation of value-based, care-delivery systems requires high-functioning units. We will need to design and lead teams from the bedside to the boardroom.

In the coming years, this leadership imperative will only intensify, as we all will be pressured to do more with less. We will be asked to improve quality and decrease costs. We will need to broaden our focus to health in addition to acute illness. Doing more with less will require courage and leadership. If you look at our growth curve to date, we have an abundance of both.

Dr. Shen is medical director of hospital medicine at Dell Children's Medical Center in Austin, Texas. He served as The Hospitalist's pediatric editor since 2010 and this marks his last column in his role as editor. In his newfound spare time, he looks forward to defining value in health care.

Clinical question: Do weekend admissions for failure to thrive (FTT) result in higher costs and length of stay (LOS)?

Background: FTT accounts for up to 5% of all admissions for children younger than 2 years of age. The optimal approach to inpatient or outpatient care is not well defined. Hospitalizations sometimes are used to facilitate costly and intense workups for organic disease. Given the nonurgent nature of this condition and expected barriers to efficient workup on weekends, it is likely that weekend admissions for FTT might not add much value.

Study design: Retrospective cohort study.

Setting: Forty-two tertiary-care pediatric hospitals.

Synopsis: A total of 23,332 children younger than 2 were studied over an eight-year period. Saturday and Sunday admissions resulted in an average increase in LOS by 1.93 days and an increase in cost by $2,785 when compared with weekday admissions. Patients admitted on weekends were more likely to have imaging studies and lab tests performed, but were less likely to have a discharge diagnosis of FTT. The authors estimate that if one-half of the weekend admissions from 2010 with a consistent FTT diagnosis at admission and discharge were converted to a Monday admission, $534,145 in savings to the health-care system would result.

One notable limitation of the authors’ conclusions is that patients admitted on weekends appeared to have more organic diagnoses documented and might in fact have been more acutely ill, requiring more workup and intervention. Researchers were not able to further explore this using the administrative data. Nonetheless, a subset of weekend admissions with a consistent FTT diagnosis appeared to represent no value added to the system, and potentially could have resulted in a $3.5 million cost savings had they simply been admitted instead on a weekday.

Bottom line: Nonurgent weekend admissions for FTT are inefficient.

Citation: Thompson RT, Bennett WE, Finnell SME, Downs SM. Increased length of stay and costs associated with weekend admissions for failure to thrive. Pediatrics. 2012;131:e805-e810.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Do weekend admissions for failure to thrive (FTT) result in higher costs and length of stay (LOS)?

Background: FTT accounts for up to 5% of all admissions for children younger than 2 years of age. The optimal approach to inpatient or outpatient care is not well defined. Hospitalizations sometimes are used to facilitate costly and intense workups for organic disease. Given the nonurgent nature of this condition and expected barriers to efficient workup on weekends, it is likely that weekend admissions for FTT might not add much value.

Study design: Retrospective cohort study.

Setting: Forty-two tertiary-care pediatric hospitals.

Synopsis: A total of 23,332 children younger than 2 were studied over an eight-year period. Saturday and Sunday admissions resulted in an average increase in LOS by 1.93 days and an increase in cost by $2,785 when compared with weekday admissions. Patients admitted on weekends were more likely to have imaging studies and lab tests performed, but were less likely to have a discharge diagnosis of FTT. The authors estimate that if one-half of the weekend admissions from 2010 with a consistent FTT diagnosis at admission and discharge were converted to a Monday admission, $534,145 in savings to the health-care system would result.

One notable limitation of the authors’ conclusions is that patients admitted on weekends appeared to have more organic diagnoses documented and might in fact have been more acutely ill, requiring more workup and intervention. Researchers were not able to further explore this using the administrative data. Nonetheless, a subset of weekend admissions with a consistent FTT diagnosis appeared to represent no value added to the system, and potentially could have resulted in a $3.5 million cost savings had they simply been admitted instead on a weekday.

Bottom line: Nonurgent weekend admissions for FTT are inefficient.

Citation: Thompson RT, Bennett WE, Finnell SME, Downs SM. Increased length of stay and costs associated with weekend admissions for failure to thrive. Pediatrics. 2012;131:e805-e810.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Do weekend admissions for failure to thrive (FTT) result in higher costs and length of stay (LOS)?

Background: FTT accounts for up to 5% of all admissions for children younger than 2 years of age. The optimal approach to inpatient or outpatient care is not well defined. Hospitalizations sometimes are used to facilitate costly and intense workups for organic disease. Given the nonurgent nature of this condition and expected barriers to efficient workup on weekends, it is likely that weekend admissions for FTT might not add much value.

Study design: Retrospective cohort study.

Setting: Forty-two tertiary-care pediatric hospitals.

Synopsis: A total of 23,332 children younger than 2 were studied over an eight-year period. Saturday and Sunday admissions resulted in an average increase in LOS by 1.93 days and an increase in cost by $2,785 when compared with weekday admissions. Patients admitted on weekends were more likely to have imaging studies and lab tests performed, but were less likely to have a discharge diagnosis of FTT. The authors estimate that if one-half of the weekend admissions from 2010 with a consistent FTT diagnosis at admission and discharge were converted to a Monday admission, $534,145 in savings to the health-care system would result.

One notable limitation of the authors’ conclusions is that patients admitted on weekends appeared to have more organic diagnoses documented and might in fact have been more acutely ill, requiring more workup and intervention. Researchers were not able to further explore this using the administrative data. Nonetheless, a subset of weekend admissions with a consistent FTT diagnosis appeared to represent no value added to the system, and potentially could have resulted in a $3.5 million cost savings had they simply been admitted instead on a weekday.

Bottom line: Nonurgent weekend admissions for FTT are inefficient.

Citation: Thompson RT, Bennett WE, Finnell SME, Downs SM. Increased length of stay and costs associated with weekend admissions for failure to thrive. Pediatrics. 2012;131:e805-e810.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the relationship between variation in resource utilization and outcomes in children with community-acquired pneumonia (CAP)?

Background: Variation in clinical care, particularly when driven by provider preferences, often highlights opportunities for improvement in the quality of our care. CAP is one of the most common reasons for hospitalization in children. The relationship between variation in care processes, utilization, and outcomes in pediatric CAP is not well defined.

Study design: Retrospective database review.

Setting: Twenty-nine freestanding children's hospitals.

Synopsis: The Pediatric Health Information System (PHIS) database was used to review utilization and outcomes data on 43,819 children admitted with nonsevere CAP during a five-year period. Substantial degrees of variation in test ordering, empiric antibiotic selection, length of stay (LOS), and 14-day readmissions were found. An association was noted between increased resource utilization—specifically, ordering of diagnostic tests—and longer LOS.

The association between increased resource utilization and LOS has been suggested in other work in respiratory illness in children. Although the retrospective nature of this work precludes detailed resolution of whether confounding by severity was an issue, this appears unlikely based on the relatively homogeneous patient populations and hospital types. Additional limitations of this work exist, and include an inability to further assess the appropriateness of the testing that was ordered—as well as relatively crude rankings of hospitals based on resource utilization. Nevertheless, in an era where a premium is placed on finding value in clinical medicine, these results should prompt further exploration of the link between testing and LOS in children hospitalized with CAP.

Bottom line: Unnecessary testing in children hospitalized with pneumonia may lead to longer LOS.

Citation: Brogan TV, Hall M, Williams DJ, et al. Variability in processes of care and outcomes among children hospitalized with community-acquired pneumonia. Ped Infect Dis J. 2012;31:1036-1041.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the relationship between variation in resource utilization and outcomes in children with community-acquired pneumonia (CAP)?

Background: Variation in clinical care, particularly when driven by provider preferences, often highlights opportunities for improvement in the quality of our care. CAP is one of the most common reasons for hospitalization in children. The relationship between variation in care processes, utilization, and outcomes in pediatric CAP is not well defined.

Study design: Retrospective database review.

Setting: Twenty-nine freestanding children's hospitals.

Synopsis: The Pediatric Health Information System (PHIS) database was used to review utilization and outcomes data on 43,819 children admitted with nonsevere CAP during a five-year period. Substantial degrees of variation in test ordering, empiric antibiotic selection, length of stay (LOS), and 14-day readmissions were found. An association was noted between increased resource utilization—specifically, ordering of diagnostic tests—and longer LOS.

The association between increased resource utilization and LOS has been suggested in other work in respiratory illness in children. Although the retrospective nature of this work precludes detailed resolution of whether confounding by severity was an issue, this appears unlikely based on the relatively homogeneous patient populations and hospital types. Additional limitations of this work exist, and include an inability to further assess the appropriateness of the testing that was ordered—as well as relatively crude rankings of hospitals based on resource utilization. Nevertheless, in an era where a premium is placed on finding value in clinical medicine, these results should prompt further exploration of the link between testing and LOS in children hospitalized with CAP.

Bottom line: Unnecessary testing in children hospitalized with pneumonia may lead to longer LOS.

Citation: Brogan TV, Hall M, Williams DJ, et al. Variability in processes of care and outcomes among children hospitalized with community-acquired pneumonia. Ped Infect Dis J. 2012;31:1036-1041.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the relationship between variation in resource utilization and outcomes in children with community-acquired pneumonia (CAP)?

Background: Variation in clinical care, particularly when driven by provider preferences, often highlights opportunities for improvement in the quality of our care. CAP is one of the most common reasons for hospitalization in children. The relationship between variation in care processes, utilization, and outcomes in pediatric CAP is not well defined.

Study design: Retrospective database review.

Setting: Twenty-nine freestanding children's hospitals.

Synopsis: The Pediatric Health Information System (PHIS) database was used to review utilization and outcomes data on 43,819 children admitted with nonsevere CAP during a five-year period. Substantial degrees of variation in test ordering, empiric antibiotic selection, length of stay (LOS), and 14-day readmissions were found. An association was noted between increased resource utilization—specifically, ordering of diagnostic tests—and longer LOS.

The association between increased resource utilization and LOS has been suggested in other work in respiratory illness in children. Although the retrospective nature of this work precludes detailed resolution of whether confounding by severity was an issue, this appears unlikely based on the relatively homogeneous patient populations and hospital types. Additional limitations of this work exist, and include an inability to further assess the appropriateness of the testing that was ordered—as well as relatively crude rankings of hospitals based on resource utilization. Nevertheless, in an era where a premium is placed on finding value in clinical medicine, these results should prompt further exploration of the link between testing and LOS in children hospitalized with CAP.

Bottom line: Unnecessary testing in children hospitalized with pneumonia may lead to longer LOS.

Citation: Brogan TV, Hall M, Williams DJ, et al. Variability in processes of care and outcomes among children hospitalized with community-acquired pneumonia. Ped Infect Dis J. 2012;31:1036-1041.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: How helpful is the “gut feeling” that clinicians might have that a child is more ill than they look?

Background: Timely recognition of serious infections in children is difficult but critical to improved outcomes. Numerous studies have examined clinical criteria and laboratory tests to distinguish viral infections from more serious bacterial infections but have demonstrated mixed results. Clinicians’ subjective impressions of patients continue to drive many care patterns, and the relevance of a gut feeling that something is wrong remains unclear.

Study design: Prospective observational study.

Setting: Primary-care clinics in Flanders, Belgium.

Synopsis: Nearly 4,000 children 0-16 years of age were evaluated after presentation for acute illness in primary-care settings. Clinical features, overall “clinical impression” (serious illness present or absent), and “gut feelings” (present, absent or unsure) that something was wrong were prospectively recorded. Serious infections were defined as hospital admissions for potential bacterial infections.

The presence of a gut feeling significantly increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and had a consistently higher specificity than clinical impression alone. The overall sensitivity of the gut feeling in this cohort was 61.9% with a specificity of 97.2%, while the positive predictive value was 10.8% and negative predictive value 99.8%. A history of convulsions and parental concerns were independently strongly associated with a positive gut feeling.

Similar to other clinical and laboratory evaluations designed to detect serious illness, the absence of a gut feeling might be the more useful finding from this study. Limitations of the data include an inability to further delve into what gives rise to a gut feeling in clinical practice as well as a moderate level of variance in the multivariate models. Additionally, only 21 children were ultimately admitted to the hospital, which, in conjunction with the subsequent power limitations, highlights the proverbial difficulty of finding that “needle in the haystack.”

Bottom line: The presence or absence of a gut feeling that something is wrong might be an important component of the history in acute childhood illness.

Citation: Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ. 2012;345:e6144.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: How helpful is the “gut feeling” that clinicians might have that a child is more ill than they look?

Background: Timely recognition of serious infections in children is difficult but critical to improved outcomes. Numerous studies have examined clinical criteria and laboratory tests to distinguish viral infections from more serious bacterial infections but have demonstrated mixed results. Clinicians’ subjective impressions of patients continue to drive many care patterns, and the relevance of a gut feeling that something is wrong remains unclear.

Study design: Prospective observational study.

Setting: Primary-care clinics in Flanders, Belgium.

Synopsis: Nearly 4,000 children 0-16 years of age were evaluated after presentation for acute illness in primary-care settings. Clinical features, overall “clinical impression” (serious illness present or absent), and “gut feelings” (present, absent or unsure) that something was wrong were prospectively recorded. Serious infections were defined as hospital admissions for potential bacterial infections.

The presence of a gut feeling significantly increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and had a consistently higher specificity than clinical impression alone. The overall sensitivity of the gut feeling in this cohort was 61.9% with a specificity of 97.2%, while the positive predictive value was 10.8% and negative predictive value 99.8%. A history of convulsions and parental concerns were independently strongly associated with a positive gut feeling.

Similar to other clinical and laboratory evaluations designed to detect serious illness, the absence of a gut feeling might be the more useful finding from this study. Limitations of the data include an inability to further delve into what gives rise to a gut feeling in clinical practice as well as a moderate level of variance in the multivariate models. Additionally, only 21 children were ultimately admitted to the hospital, which, in conjunction with the subsequent power limitations, highlights the proverbial difficulty of finding that “needle in the haystack.”

Bottom line: The presence or absence of a gut feeling that something is wrong might be an important component of the history in acute childhood illness.

Citation: Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ. 2012;345:e6144.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: How helpful is the “gut feeling” that clinicians might have that a child is more ill than they look?

Background: Timely recognition of serious infections in children is difficult but critical to improved outcomes. Numerous studies have examined clinical criteria and laboratory tests to distinguish viral infections from more serious bacterial infections but have demonstrated mixed results. Clinicians’ subjective impressions of patients continue to drive many care patterns, and the relevance of a gut feeling that something is wrong remains unclear.

Study design: Prospective observational study.

Setting: Primary-care clinics in Flanders, Belgium.

Synopsis: Nearly 4,000 children 0-16 years of age were evaluated after presentation for acute illness in primary-care settings. Clinical features, overall “clinical impression” (serious illness present or absent), and “gut feelings” (present, absent or unsure) that something was wrong were prospectively recorded. Serious infections were defined as hospital admissions for potential bacterial infections.

The presence of a gut feeling significantly increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and had a consistently higher specificity than clinical impression alone. The overall sensitivity of the gut feeling in this cohort was 61.9% with a specificity of 97.2%, while the positive predictive value was 10.8% and negative predictive value 99.8%. A history of convulsions and parental concerns were independently strongly associated with a positive gut feeling.

Similar to other clinical and laboratory evaluations designed to detect serious illness, the absence of a gut feeling might be the more useful finding from this study. Limitations of the data include an inability to further delve into what gives rise to a gut feeling in clinical practice as well as a moderate level of variance in the multivariate models. Additionally, only 21 children were ultimately admitted to the hospital, which, in conjunction with the subsequent power limitations, highlights the proverbial difficulty of finding that “needle in the haystack.”

Bottom line: The presence or absence of a gut feeling that something is wrong might be an important component of the history in acute childhood illness.

Citation: Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ. 2012;345:e6144.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What are the characteristics of interfacility transfers to pediatric academic EDs?

Background: The majority of pediatric ED visits (89%) and hospital admissions (69%) occur via general hospital EDs, not freestanding academic children's hospitals. Pediatric hospitalists often provide consultation services in these community hospital settings and might be the primary admitting team in either setting (community hospital or children's hospital). Questions concerning the quality of pediatric ED care in community hospitals have been raised, with acknowledged improvements in post-transfer care for critically ill patients. The characteristics of less acutely ill transfers are unknown and could provide insight into opportunities for improvement.

Study design: Cross-sectional, retrospective database review.

Setting: Twenty-nine tertiary-care pediatric hospitals.

Synopsis: The Pediatric Health Information System (PHIS) database of the Child Health Corporation of America was reviewed; over a one-year period, 24,905 interfacility transfers were identified from 29 hospitals. Fifty-eight percent of patients were admitted for more than 24 hours with common respiratory illnesses (pneumonia, bronchiolitis, asthma) and surgical conditions representing the most common diagnostic categories. Among the remaining patients, 24.7% were discharged directly from the academic pediatric EDs; 17% were admitted for less than 24 hours. Among those discharged or briefly admitted, common nonsurgical diagnostic categories included abdominal pain, viral gastroenteritis/dehydration, and other gastrointestinal conditions.

The authors attempted to define areas for improvement in pediatric care in community hospital EDs. Limitations of their analysis include the use of a database without validated code for source of admission, as well as an inability to drill down further into the specifics of what additional expertise was provided at the pediatric EDs. However, this study provides a platform by which pediatric hospitalists can view and subsequently improve the value of their regional care systems.

Bottom line: Interfacility transfers to pediatric academic EDs might offer an opportunity for improved pediatric care in community hospital EDs.

Citation: Li J, Monuteaux MC, Bachur RG. Interfacility transfers of noncritically ill children to academic pediatric emergency departments. Pediatrics. 2012;130:83-92.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What are the characteristics of interfacility transfers to pediatric academic EDs?

Background: The majority of pediatric ED visits (89%) and hospital admissions (69%) occur via general hospital EDs, not freestanding academic children's hospitals. Pediatric hospitalists often provide consultation services in these community hospital settings and might be the primary admitting team in either setting (community hospital or children's hospital). Questions concerning the quality of pediatric ED care in community hospitals have been raised, with acknowledged improvements in post-transfer care for critically ill patients. The characteristics of less acutely ill transfers are unknown and could provide insight into opportunities for improvement.

Study design: Cross-sectional, retrospective database review.

Setting: Twenty-nine tertiary-care pediatric hospitals.

Synopsis: The Pediatric Health Information System (PHIS) database of the Child Health Corporation of America was reviewed; over a one-year period, 24,905 interfacility transfers were identified from 29 hospitals. Fifty-eight percent of patients were admitted for more than 24 hours with common respiratory illnesses (pneumonia, bronchiolitis, asthma) and surgical conditions representing the most common diagnostic categories. Among the remaining patients, 24.7% were discharged directly from the academic pediatric EDs; 17% were admitted for less than 24 hours. Among those discharged or briefly admitted, common nonsurgical diagnostic categories included abdominal pain, viral gastroenteritis/dehydration, and other gastrointestinal conditions.

The authors attempted to define areas for improvement in pediatric care in community hospital EDs. Limitations of their analysis include the use of a database without validated code for source of admission, as well as an inability to drill down further into the specifics of what additional expertise was provided at the pediatric EDs. However, this study provides a platform by which pediatric hospitalists can view and subsequently improve the value of their regional care systems.

Bottom line: Interfacility transfers to pediatric academic EDs might offer an opportunity for improved pediatric care in community hospital EDs.

Citation: Li J, Monuteaux MC, Bachur RG. Interfacility transfers of noncritically ill children to academic pediatric emergency departments. Pediatrics. 2012;130:83-92.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What are the characteristics of interfacility transfers to pediatric academic EDs?

Background: The majority of pediatric ED visits (89%) and hospital admissions (69%) occur via general hospital EDs, not freestanding academic children's hospitals. Pediatric hospitalists often provide consultation services in these community hospital settings and might be the primary admitting team in either setting (community hospital or children's hospital). Questions concerning the quality of pediatric ED care in community hospitals have been raised, with acknowledged improvements in post-transfer care for critically ill patients. The characteristics of less acutely ill transfers are unknown and could provide insight into opportunities for improvement.

Study design: Cross-sectional, retrospective database review.

Setting: Twenty-nine tertiary-care pediatric hospitals.

Synopsis: The Pediatric Health Information System (PHIS) database of the Child Health Corporation of America was reviewed; over a one-year period, 24,905 interfacility transfers were identified from 29 hospitals. Fifty-eight percent of patients were admitted for more than 24 hours with common respiratory illnesses (pneumonia, bronchiolitis, asthma) and surgical conditions representing the most common diagnostic categories. Among the remaining patients, 24.7% were discharged directly from the academic pediatric EDs; 17% were admitted for less than 24 hours. Among those discharged or briefly admitted, common nonsurgical diagnostic categories included abdominal pain, viral gastroenteritis/dehydration, and other gastrointestinal conditions.

The authors attempted to define areas for improvement in pediatric care in community hospital EDs. Limitations of their analysis include the use of a database without validated code for source of admission, as well as an inability to drill down further into the specifics of what additional expertise was provided at the pediatric EDs. However, this study provides a platform by which pediatric hospitalists can view and subsequently improve the value of their regional care systems.

Bottom line: Interfacility transfers to pediatric academic EDs might offer an opportunity for improved pediatric care in community hospital EDs.

Citation: Li J, Monuteaux MC, Bachur RG. Interfacility transfers of noncritically ill children to academic pediatric emergency departments. Pediatrics. 2012;130:83-92.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Dr. Mark Shen, MD, FHM

As I write this column, I am on the second leg of an overnight flight back home to Austin, Texas. I think it actually went pretty well, considering my 2-year-old daughter was wide awake after sleeping for the first three hours of this 14-hour odyssey. The remainder of the trip is a blur of awkward sleep positions interspersed with brief periods of semilucidity. Those of you with first-hand knowledge of what this experience is like might be feeling sorry for me, but you shouldn’t. I am returning from a “why don’t I live here” kind of vacation week in Hawaii. The rest of you are probably wondering how anyone could write a coherent column at this point, which is fair, but to which I would reply: Aren’t all hospitalists expected to function at high levels during periods of sleep deprivation?

While the issue of resident duty-hours has been discussed endlessly and studied increasingly, in terms of effects on outcomes, I am surprised there has not been more discussion surrounding the concept of attending duty-hours. The subject might not always be phrased to include the term “duty-hours,” but it seems that when it comes to scheduling, strong opinions come out in my group when the duration of, frequency of, or time off between night shifts are brought up. And when it comes to safety, I am certain sleep deprivation and sleep inertia (that period of haziness immediately after being awakened in the middle of the night) have led to questionable decisions on my part.

Why? Well...

So why do pediatric hospitalists avoid the issue of sleep hygiene, work schedules, and clinical impact? I think the reasons are multifactorial.

First, there are definitely individual variations in how all of us tolerate this work, and I suspect some of this is based on such traits as age and general ability to adapt to uncomfortable circadian flip-flops. I will admit that every time I wake up achy after a call night, I begin to wonder if I will be able to handle this in 10 to 15 years. 

Second, I think pediatric HM as a field has not yet explored this topic fully because we are young both in terms of chronological age as well as nocturnal work-years. The work has not yet aged us to the point of making this a critical issue. We’re also somewhat behind our adult-hospitalist colleagues in terms of the volume of nocturnal work. Adult HM groups have long explored different shift schedules (seven-on/seven-off, day/evening/overnight distribution, etc.) because they routinely cover large services of more than 100 patients in large hospitals with more than 500 beds. In pediatrics, most of us operate in small community hospital settings or large academic centers where the nightly in-house quantity of work is relatively low, mitigated by the smaller size of most community programs and the presence of residents in most large children’s hospitals.

But I see this as an important issue for us to define: the imperative to define safe, round-the-clock clinical care and sustainable careers. Although we will need to learn from other fields, HM is somewhat different from other types of 24/7 medicine in that we require more continuity in our daytime work, which also carries over to night shifts both in terms of how the schedule is made as well as the benefit on the clinical side. The need for continuity adds an extra degree of difficulty in creating and studying different schedules that try to optimize nocturnal functioning.

Clarity, Please

Unfortunately, those looking for evidence-based, or even consensus-based, solutions might have to wait. A recent article in the Journal of Hospital Medicine does a nice job of synthesizing the literature and highlights the lack of clear answers for what kind of shift schedules work best.¹

In the absence of scientific solutions, it might be too easy to say that we need “more research,” because what doesn’t need more research? (OK, we don’t need more research on interventions for bronchiolitis.) But in the same manner in which pediatric hospitalists have taken the lead in defining a night curriculum for residents (congratulations, Becky Blankenburg, on winning the Ray E. Helfer award in pediatric education), I believe there is an opportunity to improve circadian functioning for all hospital-based physicians, but more specifically attendings. This is even more important as residents work less and a 24/7 attending presence becomes the norm in teaching facilities. While the link between safety and fatigue may have been seen as a nonissue in past decades, I think that in our current era, this is something that we own and/or will be asked to define in the near future.

In the meantime, I think we’re left to our own schedules. And in defense of all schedulers like me out there, I will say that there are no proven solutions, so local culture will predominate. Different groups with different personalities and family makeups will have varying preferences. Smaller groups will tend to have longer shift times with less flexibility in “swing”-type midday or evening shifts, while larger groups might have increased flexibility in defining different shifts at the expense of added complexity in terms of creating a schedule with no gaps.

As we come up with more rules about night shifts, such as “clockwise” scheduling of day-evening-overnight shifts, single versus clustered nights based on frequency, and days off after night shifts, the more complex and awkward our Tetris-like schedule will become. I predict that this is something hospitalists will begin to think about more, with a necessary push for safe and sustainable schedules. In the short-term, allowing for financial and structural wiggle room in the scheduling process (i.e. adjusting shift patterns and differential pay for night work) might be the most balanced approach for the immediate future.

Dr. Shen is pediatric editor of The Hospitalist. Write to him at mshen@seton.edu.

Reference

1. Schaefer EW, Williams MV, Zee PC. Sleep and circadian misalignment for the hospitalist: a review. J Hosp Med. 2012;7(6):489-496.

Dr. Mark Shen, MD, FHM

As I write this column, I am on the second leg of an overnight flight back home to Austin, Texas. I think it actually went pretty well, considering my 2-year-old daughter was wide awake after sleeping for the first three hours of this 14-hour odyssey. The remainder of the trip is a blur of awkward sleep positions interspersed with brief periods of semilucidity. Those of you with first-hand knowledge of what this experience is like might be feeling sorry for me, but you shouldn’t. I am returning from a “why don’t I live here” kind of vacation week in Hawaii. The rest of you are probably wondering how anyone could write a coherent column at this point, which is fair, but to which I would reply: Aren’t all hospitalists expected to function at high levels during periods of sleep deprivation?

While the issue of resident duty-hours has been discussed endlessly and studied increasingly, in terms of effects on outcomes, I am surprised there has not been more discussion surrounding the concept of attending duty-hours. The subject might not always be phrased to include the term “duty-hours,” but it seems that when it comes to scheduling, strong opinions come out in my group when the duration of, frequency of, or time off between night shifts are brought up. And when it comes to safety, I am certain sleep deprivation and sleep inertia (that period of haziness immediately after being awakened in the middle of the night) have led to questionable decisions on my part.

Why? Well...

So why do pediatric hospitalists avoid the issue of sleep hygiene, work schedules, and clinical impact? I think the reasons are multifactorial.

First, there are definitely individual variations in how all of us tolerate this work, and I suspect some of this is based on such traits as age and general ability to adapt to uncomfortable circadian flip-flops. I will admit that every time I wake up achy after a call night, I begin to wonder if I will be able to handle this in 10 to 15 years. 

Second, I think pediatric HM as a field has not yet explored this topic fully because we are young both in terms of chronological age as well as nocturnal work-years. The work has not yet aged us to the point of making this a critical issue. We’re also somewhat behind our adult-hospitalist colleagues in terms of the volume of nocturnal work. Adult HM groups have long explored different shift schedules (seven-on/seven-off, day/evening/overnight distribution, etc.) because they routinely cover large services of more than 100 patients in large hospitals with more than 500 beds. In pediatrics, most of us operate in small community hospital settings or large academic centers where the nightly in-house quantity of work is relatively low, mitigated by the smaller size of most community programs and the presence of residents in most large children’s hospitals.

But I see this as an important issue for us to define: the imperative to define safe, round-the-clock clinical care and sustainable careers. Although we will need to learn from other fields, HM is somewhat different from other types of 24/7 medicine in that we require more continuity in our daytime work, which also carries over to night shifts both in terms of how the schedule is made as well as the benefit on the clinical side. The need for continuity adds an extra degree of difficulty in creating and studying different schedules that try to optimize nocturnal functioning.

Clarity, Please

Unfortunately, those looking for evidence-based, or even consensus-based, solutions might have to wait. A recent article in the Journal of Hospital Medicine does a nice job of synthesizing the literature and highlights the lack of clear answers for what kind of shift schedules work best.¹

In the absence of scientific solutions, it might be too easy to say that we need “more research,” because what doesn’t need more research? (OK, we don’t need more research on interventions for bronchiolitis.) But in the same manner in which pediatric hospitalists have taken the lead in defining a night curriculum for residents (congratulations, Becky Blankenburg, on winning the Ray E. Helfer award in pediatric education), I believe there is an opportunity to improve circadian functioning for all hospital-based physicians, but more specifically attendings. This is even more important as residents work less and a 24/7 attending presence becomes the norm in teaching facilities. While the link between safety and fatigue may have been seen as a nonissue in past decades, I think that in our current era, this is something that we own and/or will be asked to define in the near future.

In the meantime, I think we’re left to our own schedules. And in defense of all schedulers like me out there, I will say that there are no proven solutions, so local culture will predominate. Different groups with different personalities and family makeups will have varying preferences. Smaller groups will tend to have longer shift times with less flexibility in “swing”-type midday or evening shifts, while larger groups might have increased flexibility in defining different shifts at the expense of added complexity in terms of creating a schedule with no gaps.

As we come up with more rules about night shifts, such as “clockwise” scheduling of day-evening-overnight shifts, single versus clustered nights based on frequency, and days off after night shifts, the more complex and awkward our Tetris-like schedule will become. I predict that this is something hospitalists will begin to think about more, with a necessary push for safe and sustainable schedules. In the short-term, allowing for financial and structural wiggle room in the scheduling process (i.e. adjusting shift patterns and differential pay for night work) might be the most balanced approach for the immediate future.

Dr. Shen is pediatric editor of The Hospitalist. Write to him at mshen@seton.edu.

Reference

1. Schaefer EW, Williams MV, Zee PC. Sleep and circadian misalignment for the hospitalist: a review. J Hosp Med. 2012;7(6):489-496.

Dr. Mark Shen, MD, FHM

As I write this column, I am on the second leg of an overnight flight back home to Austin, Texas. I think it actually went pretty well, considering my 2-year-old daughter was wide awake after sleeping for the first three hours of this 14-hour odyssey. The remainder of the trip is a blur of awkward sleep positions interspersed with brief periods of semilucidity. Those of you with first-hand knowledge of what this experience is like might be feeling sorry for me, but you shouldn’t. I am returning from a “why don’t I live here” kind of vacation week in Hawaii. The rest of you are probably wondering how anyone could write a coherent column at this point, which is fair, but to which I would reply: Aren’t all hospitalists expected to function at high levels during periods of sleep deprivation?

While the issue of resident duty-hours has been discussed endlessly and studied increasingly, in terms of effects on outcomes, I am surprised there has not been more discussion surrounding the concept of attending duty-hours. The subject might not always be phrased to include the term “duty-hours,” but it seems that when it comes to scheduling, strong opinions come out in my group when the duration of, frequency of, or time off between night shifts are brought up. And when it comes to safety, I am certain sleep deprivation and sleep inertia (that period of haziness immediately after being awakened in the middle of the night) have led to questionable decisions on my part.

Why? Well...

So why do pediatric hospitalists avoid the issue of sleep hygiene, work schedules, and clinical impact? I think the reasons are multifactorial.

First, there are definitely individual variations in how all of us tolerate this work, and I suspect some of this is based on such traits as age and general ability to adapt to uncomfortable circadian flip-flops. I will admit that every time I wake up achy after a call night, I begin to wonder if I will be able to handle this in 10 to 15 years. 

Second, I think pediatric HM as a field has not yet explored this topic fully because we are young both in terms of chronological age as well as nocturnal work-years. The work has not yet aged us to the point of making this a critical issue. We’re also somewhat behind our adult-hospitalist colleagues in terms of the volume of nocturnal work. Adult HM groups have long explored different shift schedules (seven-on/seven-off, day/evening/overnight distribution, etc.) because they routinely cover large services of more than 100 patients in large hospitals with more than 500 beds. In pediatrics, most of us operate in small community hospital settings or large academic centers where the nightly in-house quantity of work is relatively low, mitigated by the smaller size of most community programs and the presence of residents in most large children’s hospitals.

But I see this as an important issue for us to define: the imperative to define safe, round-the-clock clinical care and sustainable careers. Although we will need to learn from other fields, HM is somewhat different from other types of 24/7 medicine in that we require more continuity in our daytime work, which also carries over to night shifts both in terms of how the schedule is made as well as the benefit on the clinical side. The need for continuity adds an extra degree of difficulty in creating and studying different schedules that try to optimize nocturnal functioning.

Clarity, Please

Unfortunately, those looking for evidence-based, or even consensus-based, solutions might have to wait. A recent article in the Journal of Hospital Medicine does a nice job of synthesizing the literature and highlights the lack of clear answers for what kind of shift schedules work best.¹

In the absence of scientific solutions, it might be too easy to say that we need “more research,” because what doesn’t need more research? (OK, we don’t need more research on interventions for bronchiolitis.) But in the same manner in which pediatric hospitalists have taken the lead in defining a night curriculum for residents (congratulations, Becky Blankenburg, on winning the Ray E. Helfer award in pediatric education), I believe there is an opportunity to improve circadian functioning for all hospital-based physicians, but more specifically attendings. This is even more important as residents work less and a 24/7 attending presence becomes the norm in teaching facilities. While the link between safety and fatigue may have been seen as a nonissue in past decades, I think that in our current era, this is something that we own and/or will be asked to define in the near future.

In the meantime, I think we’re left to our own schedules. And in defense of all schedulers like me out there, I will say that there are no proven solutions, so local culture will predominate. Different groups with different personalities and family makeups will have varying preferences. Smaller groups will tend to have longer shift times with less flexibility in “swing”-type midday or evening shifts, while larger groups might have increased flexibility in defining different shifts at the expense of added complexity in terms of creating a schedule with no gaps.

As we come up with more rules about night shifts, such as “clockwise” scheduling of day-evening-overnight shifts, single versus clustered nights based on frequency, and days off after night shifts, the more complex and awkward our Tetris-like schedule will become. I predict that this is something hospitalists will begin to think about more, with a necessary push for safe and sustainable schedules. In the short-term, allowing for financial and structural wiggle room in the scheduling process (i.e. adjusting shift patterns and differential pay for night work) might be the most balanced approach for the immediate future.

Dr. Shen is pediatric editor of The Hospitalist. Write to him at mshen@seton.edu.

Reference

1. Schaefer EW, Williams MV, Zee PC. Sleep and circadian misalignment for the hospitalist: a review. J Hosp Med. 2012;7(6):489-496.

Clinical question: What is the association between cerebrospinal fluid (CSF) red blood cell (RBC) counts and protein concentrations in infants younger than 57 days of age?

Background: Lumbar puncture (LP) is commonly performed in young infants to evaluate for meningitis in the clinical scenario of fever without source. Traumatic LP is common in children, and higher RBC counts are associated with increased CSF protein concentrations. The dynamic nature of CSF composition in young infants makes determination of the exact relationship between RBC counts and protein concentration challenging, which then complicates interpretation of CSF.

Study design: Retrospective, cross-sectional study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a four-year period, 1,241 infants younger than 57 days of age that underwent LP were studied, excluding infants with conditions known to increase CSF protein concentrations: ventricular shunt, serious bacterial infection, congenital infection, herpes simplex virus or enterovirus positive PCR in CSF, seizure, or elevated serum bilirubin. Grossly bloody specimens with RBC counts >150,000 cells/mm3 were also excluded. Linear regression was used to determine relationship between CSF RBCs and protein, with protein increasing at a rate of 1.9 mg/dL per 1,000 CSF RBCs.

This ratio is different from a more traditional correction factor of approximately 1 mg/dL CSF protein increase per 1,000 CSF RBCs, which is derived from older populations of children.

However, this study is limited by the exclusion of grossly bloody specimens, which if included would have resulted in a ratio similar to the more traditional values. Additionally, application of this specific correction factor to prediction rules for bacterial meningitis has not been studied. Nonetheless, this study provides a baseline by which clinicians may interpret protein concentrations in traumatically bloody CSF specimens in young infants.

Bottom line: CSF protein concentrations increase at roughly 2 mg/dL per 1,000 CSF RBCs.

Citation: Hines BA, Nigrovic LE, Neuman MI, Shah SS. Adjustment of cerebrospinal fluid protein for red blood cells in neonates and young infants. J Hosp Med. 2012;7:325-328.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the association between cerebrospinal fluid (CSF) red blood cell (RBC) counts and protein concentrations in infants younger than 57 days of age?

Background: Lumbar puncture (LP) is commonly performed in young infants to evaluate for meningitis in the clinical scenario of fever without source. Traumatic LP is common in children, and higher RBC counts are associated with increased CSF protein concentrations. The dynamic nature of CSF composition in young infants makes determination of the exact relationship between RBC counts and protein concentration challenging, which then complicates interpretation of CSF.

Study design: Retrospective, cross-sectional study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a four-year period, 1,241 infants younger than 57 days of age that underwent LP were studied, excluding infants with conditions known to increase CSF protein concentrations: ventricular shunt, serious bacterial infection, congenital infection, herpes simplex virus or enterovirus positive PCR in CSF, seizure, or elevated serum bilirubin. Grossly bloody specimens with RBC counts >150,000 cells/mm3 were also excluded. Linear regression was used to determine relationship between CSF RBCs and protein, with protein increasing at a rate of 1.9 mg/dL per 1,000 CSF RBCs.

This ratio is different from a more traditional correction factor of approximately 1 mg/dL CSF protein increase per 1,000 CSF RBCs, which is derived from older populations of children.

However, this study is limited by the exclusion of grossly bloody specimens, which if included would have resulted in a ratio similar to the more traditional values. Additionally, application of this specific correction factor to prediction rules for bacterial meningitis has not been studied. Nonetheless, this study provides a baseline by which clinicians may interpret protein concentrations in traumatically bloody CSF specimens in young infants.

Bottom line: CSF protein concentrations increase at roughly 2 mg/dL per 1,000 CSF RBCs.

Citation: Hines BA, Nigrovic LE, Neuman MI, Shah SS. Adjustment of cerebrospinal fluid protein for red blood cells in neonates and young infants. J Hosp Med. 2012;7:325-328.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the association between cerebrospinal fluid (CSF) red blood cell (RBC) counts and protein concentrations in infants younger than 57 days of age?

Background: Lumbar puncture (LP) is commonly performed in young infants to evaluate for meningitis in the clinical scenario of fever without source. Traumatic LP is common in children, and higher RBC counts are associated with increased CSF protein concentrations. The dynamic nature of CSF composition in young infants makes determination of the exact relationship between RBC counts and protein concentration challenging, which then complicates interpretation of CSF.

Study design: Retrospective, cross-sectional study.

Setting: Tertiary-care children's hospital.

Synopsis: Over a four-year period, 1,241 infants younger than 57 days of age that underwent LP were studied, excluding infants with conditions known to increase CSF protein concentrations: ventricular shunt, serious bacterial infection, congenital infection, herpes simplex virus or enterovirus positive PCR in CSF, seizure, or elevated serum bilirubin. Grossly bloody specimens with RBC counts >150,000 cells/mm3 were also excluded. Linear regression was used to determine relationship between CSF RBCs and protein, with protein increasing at a rate of 1.9 mg/dL per 1,000 CSF RBCs.

This ratio is different from a more traditional correction factor of approximately 1 mg/dL CSF protein increase per 1,000 CSF RBCs, which is derived from older populations of children.

However, this study is limited by the exclusion of grossly bloody specimens, which if included would have resulted in a ratio similar to the more traditional values. Additionally, application of this specific correction factor to prediction rules for bacterial meningitis has not been studied. Nonetheless, this study provides a baseline by which clinicians may interpret protein concentrations in traumatically bloody CSF specimens in young infants.

Bottom line: CSF protein concentrations increase at roughly 2 mg/dL per 1,000 CSF RBCs.

Citation: Hines BA, Nigrovic LE, Neuman MI, Shah SS. Adjustment of cerebrospinal fluid protein for red blood cells in neonates and young infants. J Hosp Med. 2012;7:325-328.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the impact of an evidence-based care process model (EB-CPM) on outcomes and costs in febrile infants?

Background: The care of febrile infants <90 days of age is common, and national guidelines have been in existence for nearly 20 years. However, variation in practice has been noted surrounding management of these infants, and there are limited reports of outcomes and costs related to implementation of local guidelines and quality-improvement (QI) projects.

Study design: Retrospective review of QI project.

Setting: Intermountain Healthcare System in Utah.

Synopsis: Over a period of five years, 8,044 infants with 8,431 febrile episodes were evaluated within the Intermountain Healthcare System, an integrated healthcare network that provides care for about 85% of the children in Utah. The EB-CPM was implemented in the middle of this five-year span and applied modified Rochester criteria to risk-stratify infants. Low-risk infants were eligible for discharge to home; high-risk infants were admitted and received viral testing. Infants with negative bacterial cultures and positive viral studies were eligible for discharge at 24 hours. For the remainder of admitted infants, discharge was recommended after 36 hours of negative bacterial cultures.

The review showed no statistically significant differences in readmissions or admission rates for serious bacterial infection before and after the implementation. There were significant reductions in mean hospital length of stay (60 to 44 hours, P<0.001) and cost per admitted infant ($7,178 to $5,979, P<0.001) after the EB-CPM was released. Cost savings were estimated at $1.9 million during the five-year study period.

Several limitations of this study are relevant. First, this QI project occurred within the confines of an integrated healthcare delivery system, a context that is uncommon in most of the country. Compliance with recommendations was not universal, which suggests that there is potential for improvement upon these results, or that clinical judgment played a significant role in decision-making.

Nonetheless, this report demonstrates that there is significant potential for cost savings with focused recommendations for discharge of febrile infants.

Bottom line: Standardized recommendations for discharge in febrile infants could result in substantial cost savings.

Citation: Byington CL, Reynolds CC, Korgenski K, et al. Cost and infant outcomes after implementation of a care process model for febrile infants. Pediatrics. 2012;130:e16-e24.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the impact of an evidence-based care process model (EB-CPM) on outcomes and costs in febrile infants?

Background: The care of febrile infants <90 days of age is common, and national guidelines have been in existence for nearly 20 years. However, variation in practice has been noted surrounding management of these infants, and there are limited reports of outcomes and costs related to implementation of local guidelines and quality-improvement (QI) projects.

Study design: Retrospective review of QI project.

Setting: Intermountain Healthcare System in Utah.

Synopsis: Over a period of five years, 8,044 infants with 8,431 febrile episodes were evaluated within the Intermountain Healthcare System, an integrated healthcare network that provides care for about 85% of the children in Utah. The EB-CPM was implemented in the middle of this five-year span and applied modified Rochester criteria to risk-stratify infants. Low-risk infants were eligible for discharge to home; high-risk infants were admitted and received viral testing. Infants with negative bacterial cultures and positive viral studies were eligible for discharge at 24 hours. For the remainder of admitted infants, discharge was recommended after 36 hours of negative bacterial cultures.

The review showed no statistically significant differences in readmissions or admission rates for serious bacterial infection before and after the implementation. There were significant reductions in mean hospital length of stay (60 to 44 hours, P<0.001) and cost per admitted infant ($7,178 to $5,979, P<0.001) after the EB-CPM was released. Cost savings were estimated at $1.9 million during the five-year study period.

Several limitations of this study are relevant. First, this QI project occurred within the confines of an integrated healthcare delivery system, a context that is uncommon in most of the country. Compliance with recommendations was not universal, which suggests that there is potential for improvement upon these results, or that clinical judgment played a significant role in decision-making.

Nonetheless, this report demonstrates that there is significant potential for cost savings with focused recommendations for discharge of febrile infants.

Bottom line: Standardized recommendations for discharge in febrile infants could result in substantial cost savings.

Citation: Byington CL, Reynolds CC, Korgenski K, et al. Cost and infant outcomes after implementation of a care process model for febrile infants. Pediatrics. 2012;130:e16-e24.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the impact of an evidence-based care process model (EB-CPM) on outcomes and costs in febrile infants?

Background: The care of febrile infants <90 days of age is common, and national guidelines have been in existence for nearly 20 years. However, variation in practice has been noted surrounding management of these infants, and there are limited reports of outcomes and costs related to implementation of local guidelines and quality-improvement (QI) projects.

Study design: Retrospective review of QI project.

Setting: Intermountain Healthcare System in Utah.

Synopsis: Over a period of five years, 8,044 infants with 8,431 febrile episodes were evaluated within the Intermountain Healthcare System, an integrated healthcare network that provides care for about 85% of the children in Utah. The EB-CPM was implemented in the middle of this five-year span and applied modified Rochester criteria to risk-stratify infants. Low-risk infants were eligible for discharge to home; high-risk infants were admitted and received viral testing. Infants with negative bacterial cultures and positive viral studies were eligible for discharge at 24 hours. For the remainder of admitted infants, discharge was recommended after 36 hours of negative bacterial cultures.

The review showed no statistically significant differences in readmissions or admission rates for serious bacterial infection before and after the implementation. There were significant reductions in mean hospital length of stay (60 to 44 hours, P<0.001) and cost per admitted infant ($7,178 to $5,979, P<0.001) after the EB-CPM was released. Cost savings were estimated at $1.9 million during the five-year study period.

Several limitations of this study are relevant. First, this QI project occurred within the confines of an integrated healthcare delivery system, a context that is uncommon in most of the country. Compliance with recommendations was not universal, which suggests that there is potential for improvement upon these results, or that clinical judgment played a significant role in decision-making.

Nonetheless, this report demonstrates that there is significant potential for cost savings with focused recommendations for discharge of febrile infants.

Bottom line: Standardized recommendations for discharge in febrile infants could result in substantial cost savings.

Citation: Byington CL, Reynolds CC, Korgenski K, et al. Cost and infant outcomes after implementation of a care process model for febrile infants. Pediatrics. 2012;130:e16-e24.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the epidemiology of bacteremia in one-week to three-month-old infants?

Background: Large studies of bacteremia in infants <90 days of age were largely performed before the era of routine prenatal screening and prophylaxis for Group B Streptococcus (GBS). Additionally, these studies have focused on febrile infants, which might not allow for characterization of the incidence of bacteremia when nonfebrile infants are considered.

Study design: Retrospective review.

Setting: Large HMO database.

Synopsis: Of 160,818 full-term infants born at Kaiser Permanente Northern California from 2005 to 2009, 4,255 blood cultures were obtained from 4,122 infants in outpatient clinics, the ED, or in an inpatient setting within 24 hours of birth. Preterm infants <37 weeks, infants with underlying medical conditions, and infants with cultures drawn within three days of an original culture were excluded.

A total of 8% of the blood cultures were positive, with 2.2% deemed true positives and 5.8% due to contaminants. The incidence rate of true bacteremia was 0.57 per 1,000 full-term births, with gram-negative organisms (predominantly Escherichia coli) representing the majority (63%) of pathogens, followed by GBS (21%), Staphylococcus aureus (8%), and Streptococcus pneumoniae (3%). There were no cases of Listeria monocytogenes or Neisseria meningitidis bacteremia, and there was one case of enterococcal bacteremia. Fever was absent in 7% of cases.

The authors conclude that ampicillin may no longer be necessary for empiric antibiotic coverage in this age group given that 36% of pathogens were resistant to ampicillin, there were no cases of Listeria, and there was only one case of enterococcus. However, these recommendations should be considered in light of the specific study setting, and might not be applicable to all areas.

Bottom line: E. coli, GBS, and S. aureus, in that order, are the most common causes of bacteremia in infants aged one week to three months.

Citation: Greenhow TL, Hung YY, Herz AM. Changing epidemiology of bacteremia in infants aged 1 week to 3 months. Pediatrics. 2012;129(3):e590-e596.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the epidemiology of bacteremia in one-week to three-month-old infants?

Background: Large studies of bacteremia in infants <90 days of age were largely performed before the era of routine prenatal screening and prophylaxis for Group B Streptococcus (GBS). Additionally, these studies have focused on febrile infants, which might not allow for characterization of the incidence of bacteremia when nonfebrile infants are considered.

Study design: Retrospective review.

Setting: Large HMO database.

Synopsis: Of 160,818 full-term infants born at Kaiser Permanente Northern California from 2005 to 2009, 4,255 blood cultures were obtained from 4,122 infants in outpatient clinics, the ED, or in an inpatient setting within 24 hours of birth. Preterm infants <37 weeks, infants with underlying medical conditions, and infants with cultures drawn within three days of an original culture were excluded.

A total of 8% of the blood cultures were positive, with 2.2% deemed true positives and 5.8% due to contaminants. The incidence rate of true bacteremia was 0.57 per 1,000 full-term births, with gram-negative organisms (predominantly Escherichia coli) representing the majority (63%) of pathogens, followed by GBS (21%), Staphylococcus aureus (8%), and Streptococcus pneumoniae (3%). There were no cases of Listeria monocytogenes or Neisseria meningitidis bacteremia, and there was one case of enterococcal bacteremia. Fever was absent in 7% of cases.

The authors conclude that ampicillin may no longer be necessary for empiric antibiotic coverage in this age group given that 36% of pathogens were resistant to ampicillin, there were no cases of Listeria, and there was only one case of enterococcus. However, these recommendations should be considered in light of the specific study setting, and might not be applicable to all areas.

Bottom line: E. coli, GBS, and S. aureus, in that order, are the most common causes of bacteremia in infants aged one week to three months.

Citation: Greenhow TL, Hung YY, Herz AM. Changing epidemiology of bacteremia in infants aged 1 week to 3 months. Pediatrics. 2012;129(3):e590-e596.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: What is the epidemiology of bacteremia in one-week to three-month-old infants?

Background: Large studies of bacteremia in infants <90 days of age were largely performed before the era of routine prenatal screening and prophylaxis for Group B Streptococcus (GBS). Additionally, these studies have focused on febrile infants, which might not allow for characterization of the incidence of bacteremia when nonfebrile infants are considered.

Study design: Retrospective review.

Setting: Large HMO database.

Synopsis: Of 160,818 full-term infants born at Kaiser Permanente Northern California from 2005 to 2009, 4,255 blood cultures were obtained from 4,122 infants in outpatient clinics, the ED, or in an inpatient setting within 24 hours of birth. Preterm infants <37 weeks, infants with underlying medical conditions, and infants with cultures drawn within three days of an original culture were excluded.

A total of 8% of the blood cultures were positive, with 2.2% deemed true positives and 5.8% due to contaminants. The incidence rate of true bacteremia was 0.57 per 1,000 full-term births, with gram-negative organisms (predominantly Escherichia coli) representing the majority (63%) of pathogens, followed by GBS (21%), Staphylococcus aureus (8%), and Streptococcus pneumoniae (3%). There were no cases of Listeria monocytogenes or Neisseria meningitidis bacteremia, and there was one case of enterococcal bacteremia. Fever was absent in 7% of cases.

The authors conclude that ampicillin may no longer be necessary for empiric antibiotic coverage in this age group given that 36% of pathogens were resistant to ampicillin, there were no cases of Listeria, and there was only one case of enterococcus. However, these recommendations should be considered in light of the specific study setting, and might not be applicable to all areas.

Bottom line: E. coli, GBS, and S. aureus, in that order, are the most common causes of bacteremia in infants aged one week to three months.

Citation: Greenhow TL, Hung YY, Herz AM. Changing epidemiology of bacteremia in infants aged 1 week to 3 months. Pediatrics. 2012;129(3):e590-e596.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.