Weijen Chang, MD, SFHM

Clinical question: Does artificial elevation of pulse oximetry measurement in bronchiolitis patients during ED evaluations affect hospitalization rates?

Background: Bronchiolitis is the leading cause of hospitalization for infants younger than one year, leading to direct medical costs in the U.S. of $543 million in 2002. Compromised oxyhemoglobin saturation in bronchiolitis often leads to hospitalization and is assessed by pulse oximetry (SpO2) more commonly than by arterial blood gas (SaO2) due to ease, cost, and comfort considerations.

SpO2 can vary due to fever, acidosis, hemoglobinopathies, underperfusion, and poor probe placement. An American Academy of Pediatrics clinical practice guideline published in 2006 recommended supplemental oxygen if SpO2 drops below 90% in previously healthy infants, but the data supporting this cutoff are sparse.

Recommendations for supplemental oxygen, and thus hospitalization, are variable, with recommended minimum SpO2 ranging from 90 to 95%.

Study design: Single-center randomized, double-blind, parallel-group trial.

Setting: ED at 370-bed, urban, tertiary care children’s hospital.

Synopsis: Over a 50-month period, previously healthy infants aged four weeks to 12 months who were diagnosed with bronchiolitis in the ED and had initial triage SpO2 above 88% were enrolled by investigators. Subjects were excluded if severe respiratory distress, as measured by the Respiratory Distress Assessment Instrument (RDAI), or impending respiratory failure was present. Subjects were randomized to two groups: The control group had their true SpO2 displayed during their ED stay, and the intervention group had an SpO2 that was three points higher displayed. ED physicians were not aware of the primary hypothesis being tested. All subjects underwent concealed continuous oximetry for safety reasons, with monitors alarming if SpO2 dropped below 92%. Study nurses telephoned participants discharged home 72 hours after enrollment.

The primary outcome of hospitalization was defined as admission to an inpatient ward, hospital care provided for more than six hours in the ED if no hospital beds were available, or hospitalization after discharge if within 72 hours of enrollment. Secondary outcomes included supplemental oxygen administration, length of stay in the ED, and unscheduled return visits for bronchiolitis within 72 hours. Exploratory outcomes included delayed hospitalizations within 72 hours, active hospital treatment for more than six hours (with inhaled bronchodilators, oxygen, or intravenous fluids), and hospitalization at the index visit.

Of 1,812 patients assessed, 213 were randomized after exclusion criteria and consent. The “true” group and the “altered” group were similar in initial RDAI (8.0 vs. 8.3 respectively); 41% of children in the “true” oximetry group were hospitalized within 72 hours, compared with 25% in the “high” oximetry group (P 0.005). There were no significant differences in the secondary outcomes. The only exploratory outcome to show a significant difference was treatment for longer than six hours, with 37% of the “true group” receiving treatment for longer than six hours, compared to 20% of the “altered” group (P 0.01).

Bottom line: Perception of improved oxygenation based on falsely elevated SpO2 alone can reduce the inclination of a clinician to admit children with bronchiolitis. This brings into question the use and interpretation of SpO2 in treating children with bronchiolitis.

Citation: Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-728.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: Does artificial elevation of pulse oximetry measurement in bronchiolitis patients during ED evaluations affect hospitalization rates?

Background: Bronchiolitis is the leading cause of hospitalization for infants younger than one year, leading to direct medical costs in the U.S. of $543 million in 2002. Compromised oxyhemoglobin saturation in bronchiolitis often leads to hospitalization and is assessed by pulse oximetry (SpO2) more commonly than by arterial blood gas (SaO2) due to ease, cost, and comfort considerations.

SpO2 can vary due to fever, acidosis, hemoglobinopathies, underperfusion, and poor probe placement. An American Academy of Pediatrics clinical practice guideline published in 2006 recommended supplemental oxygen if SpO2 drops below 90% in previously healthy infants, but the data supporting this cutoff are sparse.

Recommendations for supplemental oxygen, and thus hospitalization, are variable, with recommended minimum SpO2 ranging from 90 to 95%.

Study design: Single-center randomized, double-blind, parallel-group trial.

Setting: ED at 370-bed, urban, tertiary care children’s hospital.

Synopsis: Over a 50-month period, previously healthy infants aged four weeks to 12 months who were diagnosed with bronchiolitis in the ED and had initial triage SpO2 above 88% were enrolled by investigators. Subjects were excluded if severe respiratory distress, as measured by the Respiratory Distress Assessment Instrument (RDAI), or impending respiratory failure was present. Subjects were randomized to two groups: The control group had their true SpO2 displayed during their ED stay, and the intervention group had an SpO2 that was three points higher displayed. ED physicians were not aware of the primary hypothesis being tested. All subjects underwent concealed continuous oximetry for safety reasons, with monitors alarming if SpO2 dropped below 92%. Study nurses telephoned participants discharged home 72 hours after enrollment.

The primary outcome of hospitalization was defined as admission to an inpatient ward, hospital care provided for more than six hours in the ED if no hospital beds were available, or hospitalization after discharge if within 72 hours of enrollment. Secondary outcomes included supplemental oxygen administration, length of stay in the ED, and unscheduled return visits for bronchiolitis within 72 hours. Exploratory outcomes included delayed hospitalizations within 72 hours, active hospital treatment for more than six hours (with inhaled bronchodilators, oxygen, or intravenous fluids), and hospitalization at the index visit.

Of 1,812 patients assessed, 213 were randomized after exclusion criteria and consent. The “true” group and the “altered” group were similar in initial RDAI (8.0 vs. 8.3 respectively); 41% of children in the “true” oximetry group were hospitalized within 72 hours, compared with 25% in the “high” oximetry group (P 0.005). There were no significant differences in the secondary outcomes. The only exploratory outcome to show a significant difference was treatment for longer than six hours, with 37% of the “true group” receiving treatment for longer than six hours, compared to 20% of the “altered” group (P 0.01).

Bottom line: Perception of improved oxygenation based on falsely elevated SpO2 alone can reduce the inclination of a clinician to admit children with bronchiolitis. This brings into question the use and interpretation of SpO2 in treating children with bronchiolitis.

Citation: Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-728.

---

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: Does artificial elevation of pulse oximetry measurement in bronchiolitis patients during ED evaluations affect hospitalization rates?

Background: Bronchiolitis is the leading cause of hospitalization for infants younger than one year, leading to direct medical costs in the U.S. of $543 million in 2002. Compromised oxyhemoglobin saturation in bronchiolitis often leads to hospitalization and is assessed by pulse oximetry (SpO2) more commonly than by arterial blood gas (SaO2) due to ease, cost, and comfort considerations.

SpO2 can vary due to fever, acidosis, hemoglobinopathies, underperfusion, and poor probe placement. An American Academy of Pediatrics clinical practice guideline published in 2006 recommended supplemental oxygen if SpO2 drops below 90% in previously healthy infants, but the data supporting this cutoff are sparse.

Recommendations for supplemental oxygen, and thus hospitalization, are variable, with recommended minimum SpO2 ranging from 90 to 95%.

Study design: Single-center randomized, double-blind, parallel-group trial.

Setting: ED at 370-bed, urban, tertiary care children’s hospital.

Synopsis: Over a 50-month period, previously healthy infants aged four weeks to 12 months who were diagnosed with bronchiolitis in the ED and had initial triage SpO2 above 88% were enrolled by investigators. Subjects were excluded if severe respiratory distress, as measured by the Respiratory Distress Assessment Instrument (RDAI), or impending respiratory failure was present. Subjects were randomized to two groups: The control group had their true SpO2 displayed during their ED stay, and the intervention group had an SpO2 that was three points higher displayed. ED physicians were not aware of the primary hypothesis being tested. All subjects underwent concealed continuous oximetry for safety reasons, with monitors alarming if SpO2 dropped below 92%. Study nurses telephoned participants discharged home 72 hours after enrollment.

The primary outcome of hospitalization was defined as admission to an inpatient ward, hospital care provided for more than six hours in the ED if no hospital beds were available, or hospitalization after discharge if within 72 hours of enrollment. Secondary outcomes included supplemental oxygen administration, length of stay in the ED, and unscheduled return visits for bronchiolitis within 72 hours. Exploratory outcomes included delayed hospitalizations within 72 hours, active hospital treatment for more than six hours (with inhaled bronchodilators, oxygen, or intravenous fluids), and hospitalization at the index visit.

Of 1,812 patients assessed, 213 were randomized after exclusion criteria and consent. The “true” group and the “altered” group were similar in initial RDAI (8.0 vs. 8.3 respectively); 41% of children in the “true” oximetry group were hospitalized within 72 hours, compared with 25% in the “high” oximetry group (P 0.005). There were no significant differences in the secondary outcomes. The only exploratory outcome to show a significant difference was treatment for longer than six hours, with 37% of the “true group” receiving treatment for longer than six hours, compared to 20% of the “altered” group (P 0.01).

Bottom line: Perception of improved oxygenation based on falsely elevated SpO2 alone can reduce the inclination of a clinician to admit children with bronchiolitis. This brings into question the use and interpretation of SpO2 in treating children with bronchiolitis.

Citation: Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-728.

---

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: Are clinical outcomes for dexamethasone equivalent to currently recommended corticosteroids for the treatment of children with mild to moderate asthma exacerbations?

Background: National and international guidelines uniformly agree that administration of a systemic corticosteroid is appropriate for children hospitalized with mild to moderate asthma exacerbations. Based on available literature, a 2007 update to an expert panel report developed by the National Asthma Education and Prevention Program recommended prednisone, methylprednisolone, or prednisolone at 1-2 mg/kg daily in two divided doses (maximum 60 mg/day).

Recent small studies have begun to examine the use of dexamethasone in acute asthma exacerbations. The longer half-life of dexamethasone enables shorter treatment regimens, which can improve compliance. Additionally, its taste is considered superior compared to currently recommended corticosteroids.

Study designs: Two meta-analyses of randomized controlled trials (RCT).

Setting: Six RCTs published between 1997 and 2008.

Synopsis: Both groups searched Medline for RCTs using the search terms “dexamethasone” and “asthma”; additional search terms included “decadron” and “status asthmaticus.” Limiting the search to a pediatric population was achieved by either using appropriate medical subject heading terms or by using an age limiter of ≤18 years of age.

Both groups performed meta-analyses of clinical outcomes, including rates of revisit to a healthcare provider and symptomatic improvement. Adverse effects, specifically vomiting, also underwent meta-analysis by both groups.

Interestingly, both groups analyzed the same six studies, and all six studies were in the ED setting. The dexamethasone regimens in the analyzed studies included single-dose intramuscular (0.3-1.7 mg/kg), single-dose oral (0.6 mg/kg), or two-dose (0.6 mg/kg/day given once daily) oral regimens. These were compared to three- or five-day regimens of prednisone or prednisolone. Not surprisingly, both groups reached similar conclusions.

Regarding symptomatic improvement and revisit rates, there was no significant difference between dexamethasone and prednisone/prednisolone groups. Vomiting was less likely in the dexamethasone groups overall.

Bottom line: Meta-analyses of small RCTs examining dexamethasone in the treatment of acute asthma exacerbations show that it is equivalent to prednisone/prednisolone in symptomatic improvement and risk of revisit, and possibly superior with regard to the risk of vomiting.

Citations: Meyer JS, Riese J, Biondi E. Is dexamethasone an effective alternative to oral prednisone in the treatment of pediatric asthma exacerbations? Hosp Pediatr. 2014;4(3):172-180. Keeney GE, Gray MP, Morrison AK. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014;133(3):493-499.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: Are clinical outcomes for dexamethasone equivalent to currently recommended corticosteroids for the treatment of children with mild to moderate asthma exacerbations?

Background: National and international guidelines uniformly agree that administration of a systemic corticosteroid is appropriate for children hospitalized with mild to moderate asthma exacerbations. Based on available literature, a 2007 update to an expert panel report developed by the National Asthma Education and Prevention Program recommended prednisone, methylprednisolone, or prednisolone at 1-2 mg/kg daily in two divided doses (maximum 60 mg/day).

Recent small studies have begun to examine the use of dexamethasone in acute asthma exacerbations. The longer half-life of dexamethasone enables shorter treatment regimens, which can improve compliance. Additionally, its taste is considered superior compared to currently recommended corticosteroids.

Study designs: Two meta-analyses of randomized controlled trials (RCT).

Setting: Six RCTs published between 1997 and 2008.

Synopsis: Both groups searched Medline for RCTs using the search terms “dexamethasone” and “asthma”; additional search terms included “decadron” and “status asthmaticus.” Limiting the search to a pediatric population was achieved by either using appropriate medical subject heading terms or by using an age limiter of ≤18 years of age.

Both groups performed meta-analyses of clinical outcomes, including rates of revisit to a healthcare provider and symptomatic improvement. Adverse effects, specifically vomiting, also underwent meta-analysis by both groups.

Interestingly, both groups analyzed the same six studies, and all six studies were in the ED setting. The dexamethasone regimens in the analyzed studies included single-dose intramuscular (0.3-1.7 mg/kg), single-dose oral (0.6 mg/kg), or two-dose (0.6 mg/kg/day given once daily) oral regimens. These were compared to three- or five-day regimens of prednisone or prednisolone. Not surprisingly, both groups reached similar conclusions.

Regarding symptomatic improvement and revisit rates, there was no significant difference between dexamethasone and prednisone/prednisolone groups. Vomiting was less likely in the dexamethasone groups overall.

Bottom line: Meta-analyses of small RCTs examining dexamethasone in the treatment of acute asthma exacerbations show that it is equivalent to prednisone/prednisolone in symptomatic improvement and risk of revisit, and possibly superior with regard to the risk of vomiting.

Citations: Meyer JS, Riese J, Biondi E. Is dexamethasone an effective alternative to oral prednisone in the treatment of pediatric asthma exacerbations? Hosp Pediatr. 2014;4(3):172-180. Keeney GE, Gray MP, Morrison AK. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014;133(3):493-499.

---

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: Are clinical outcomes for dexamethasone equivalent to currently recommended corticosteroids for the treatment of children with mild to moderate asthma exacerbations?

Background: National and international guidelines uniformly agree that administration of a systemic corticosteroid is appropriate for children hospitalized with mild to moderate asthma exacerbations. Based on available literature, a 2007 update to an expert panel report developed by the National Asthma Education and Prevention Program recommended prednisone, methylprednisolone, or prednisolone at 1-2 mg/kg daily in two divided doses (maximum 60 mg/day).

Recent small studies have begun to examine the use of dexamethasone in acute asthma exacerbations. The longer half-life of dexamethasone enables shorter treatment regimens, which can improve compliance. Additionally, its taste is considered superior compared to currently recommended corticosteroids.

Study designs: Two meta-analyses of randomized controlled trials (RCT).

Setting: Six RCTs published between 1997 and 2008.

Synopsis: Both groups searched Medline for RCTs using the search terms “dexamethasone” and “asthma”; additional search terms included “decadron” and “status asthmaticus.” Limiting the search to a pediatric population was achieved by either using appropriate medical subject heading terms or by using an age limiter of ≤18 years of age.

Both groups performed meta-analyses of clinical outcomes, including rates of revisit to a healthcare provider and symptomatic improvement. Adverse effects, specifically vomiting, also underwent meta-analysis by both groups.

Interestingly, both groups analyzed the same six studies, and all six studies were in the ED setting. The dexamethasone regimens in the analyzed studies included single-dose intramuscular (0.3-1.7 mg/kg), single-dose oral (0.6 mg/kg), or two-dose (0.6 mg/kg/day given once daily) oral regimens. These were compared to three- or five-day regimens of prednisone or prednisolone. Not surprisingly, both groups reached similar conclusions.

Regarding symptomatic improvement and revisit rates, there was no significant difference between dexamethasone and prednisone/prednisolone groups. Vomiting was less likely in the dexamethasone groups overall.

Bottom line: Meta-analyses of small RCTs examining dexamethasone in the treatment of acute asthma exacerbations show that it is equivalent to prednisone/prednisolone in symptomatic improvement and risk of revisit, and possibly superior with regard to the risk of vomiting.

Citations: Meyer JS, Riese J, Biondi E. Is dexamethasone an effective alternative to oral prednisone in the treatment of pediatric asthma exacerbations? Hosp Pediatr. 2014;4(3):172-180. Keeney GE, Gray MP, Morrison AK. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014;133(3):493-499.

---

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Surrounded by the bucolic grounds of the Disney Yacht and Beach Club Resort in Lake Buena Vista, Fla., more than 800 pediatric hospitalists gathered in July for Pediatric Hospital Medicine 2014 (PHM14). Preceded by the Society for Pediatric Sedation’s pre-course, PHM14 began in earnest with a warm welcome from Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs at St. Louis (Mo.) Children’s Hospital and chair of the PHM14 organizing committee.

The first day of the conference started with Patrick Conway, MD, MSc, FAAP, MHM, chief medical officer for the Centers for Medicare and Medicaid Services (CMS), who gave an update of ongoing reforms in the U.S. health delivery system, with a focus on pediatrics. With three years of experience as CMS’ top doc, Dr. Conway related the difficulties of going from an unsustainable fee-for-service system to a people-centered, outcomes-driven system.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement and population health.” This practice, he added, means that the six goals of the CMS Quality Strategy align well with ongoing efforts in PHM.

Despite the difficulties of instituting change in a system that handles $3 billion daily, Dr. Conway, formerly a pediatric hospitalist at Cincinnati Children’s Hospital, said he’s witnessed many signs of improvement in the CMS landscape. Preliminary data from 2012-2014, he said, have shown a 9% reduction in hospital-acquired conditions across all measures, and overall hospital utilization is “dropping like a rock.”

While “having a foot in the boat and a foot on the dock” has been difficult, the transition, through its alphabet soup of innovation programs, is now beginning to pay off. Giving providers a pathway through the changing landscape of risk, Dr. Conway said, is an ongoing priority.

Wrapping up the first day, three healthcare system CEOs took the stage to answer questions from the audience, with Mark Shen, MD, SFHM, president of Dell Children’s Medical Center of Central Texas in Austin, Texas, posing questions like a seasoned talk show host. Panel members included David J. Bailey, MD, MBA, president and CEO of the Nemours Foundation; Steve Narang, MD, MHCM, FAAP, CEO of Banner Good Samaritan Medical Center in Phoenix, Ariz.; and Jeff Sperring, MD, FAAP, president and CEO of Riley Hospital for Children at Indiana University Health in Indianapolis.

Questions were wide-ranging.

Q: How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

Q: What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds. …It depends on ACO penetration, whether quality or volume will be the driver over the next three to five years,” Dr. Narang said.

Q: If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. I don’t think we’re going to be at a point where certification will limit being a hospitalist anytime soon,” Dr. Shen said.

Q: What are the three most important things, from a CEO perspective, that a hospitalist should know?

“Know where your organization wants to go,” Dr. Sperring said.

The next day kicked off with an inspiring call to action by Steve Meuthing, MD, vice president for safety at Cincinnati Children’s Hospital Medical Center. He called on pediatric hospitalists to eliminate all serious harm from children’s hospitals in the U.S. As a part of the Children’s Hospitals’ Solutions for Patient Safety (SPS) network, an organization accounting for 25% of all children hospitalized in the U.S., Dr. Meuthing related the need to employ high reliability theory, along with operational and cultural changes, to improve reliability in patient safety.

 

“If you don’t standardize, the rest is just chaos,” he said. “We have to make it easy to do these things.”

Dr. Meuthing said improving process reliability is key to reducing adverse outcomes, and high reliability organizations have utilized this approach to reduce serious harm events across the 81 SPS hospitals. While prevention of patient harm is the goal, an additional benefit is cost savings. He estimated $27 million of cost savings was realized within SPS network hospitals in 2012-2013.

Oral abstract and conundrum presentations, concurrent with 23 sessions across nine tracks, kept attendees busy. Topics ranged from a PHM circumcision service to decreasing overuse of continuous pulse oximetry. The day’s talks wrapped up with the respective presidents of the meeting’s co-sponsors—the American Academy of Pediatrics, the American Pediatrics Association, and SHM—sharing their organizations’ visions of PHM’s future in a town hall format.

The second full day began with an update of the Joint Council of Pediatric Hospital Medicine’s efforts to further advance PHM as a field. The process of submitting a petition to the American Board of Pediatrics was reviewed, as were the current status and time course of the move toward Accreditation Council for Graduate Medical Education certification.

After lunch, the highly anticipated “Top Articles” session was presented by Robert Dudas, MD, medical director of the pediatric hospitalist program at Johns Hopkins Bayview Medical Center in Baltimore, and Karen Wilson, MD, MPH, section head for pediatric hospital medicine at Children’s Hospital Colorado in Aurora. The presenters reviewed literature from the past year on topics ranging from nebulized hypertonic saline for bronchiolitis to antibiotic prophylaxis in vesicoureteral reflux.

The final day commenced with a talk by Alberto Puig, MD, PhD, FACP, associate director of undergraduate education at Massachusetts General Hospital in Boston, whose experiences as an internist provided insight regarding the history of the physical examination, from the aphorisms of Hippocrates to the family-centered bedside rounding of today.

---

Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.

Dr. O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

Dr. Hale is a past member of Team Hospitalist and a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Surrounded by the bucolic grounds of the Disney Yacht and Beach Club Resort in Lake Buena Vista, Fla., more than 800 pediatric hospitalists gathered in July for Pediatric Hospital Medicine 2014 (PHM14). Preceded by the Society for Pediatric Sedation’s pre-course, PHM14 began in earnest with a warm welcome from Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs at St. Louis (Mo.) Children’s Hospital and chair of the PHM14 organizing committee.

The first day of the conference started with Patrick Conway, MD, MSc, FAAP, MHM, chief medical officer for the Centers for Medicare and Medicaid Services (CMS), who gave an update of ongoing reforms in the U.S. health delivery system, with a focus on pediatrics. With three years of experience as CMS’ top doc, Dr. Conway related the difficulties of going from an unsustainable fee-for-service system to a people-centered, outcomes-driven system.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement and population health.” This practice, he added, means that the six goals of the CMS Quality Strategy align well with ongoing efforts in PHM.

Despite the difficulties of instituting change in a system that handles $3 billion daily, Dr. Conway, formerly a pediatric hospitalist at Cincinnati Children’s Hospital, said he’s witnessed many signs of improvement in the CMS landscape. Preliminary data from 2012-2014, he said, have shown a 9% reduction in hospital-acquired conditions across all measures, and overall hospital utilization is “dropping like a rock.”

While “having a foot in the boat and a foot on the dock” has been difficult, the transition, through its alphabet soup of innovation programs, is now beginning to pay off. Giving providers a pathway through the changing landscape of risk, Dr. Conway said, is an ongoing priority.

Wrapping up the first day, three healthcare system CEOs took the stage to answer questions from the audience, with Mark Shen, MD, SFHM, president of Dell Children’s Medical Center of Central Texas in Austin, Texas, posing questions like a seasoned talk show host. Panel members included David J. Bailey, MD, MBA, president and CEO of the Nemours Foundation; Steve Narang, MD, MHCM, FAAP, CEO of Banner Good Samaritan Medical Center in Phoenix, Ariz.; and Jeff Sperring, MD, FAAP, president and CEO of Riley Hospital for Children at Indiana University Health in Indianapolis.

Questions were wide-ranging.

Q: How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

Q: What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds. …It depends on ACO penetration, whether quality or volume will be the driver over the next three to five years,” Dr. Narang said.

Q: If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. I don’t think we’re going to be at a point where certification will limit being a hospitalist anytime soon,” Dr. Shen said.

Q: What are the three most important things, from a CEO perspective, that a hospitalist should know?

“Know where your organization wants to go,” Dr. Sperring said.

The next day kicked off with an inspiring call to action by Steve Meuthing, MD, vice president for safety at Cincinnati Children’s Hospital Medical Center. He called on pediatric hospitalists to eliminate all serious harm from children’s hospitals in the U.S. As a part of the Children’s Hospitals’ Solutions for Patient Safety (SPS) network, an organization accounting for 25% of all children hospitalized in the U.S., Dr. Meuthing related the need to employ high reliability theory, along with operational and cultural changes, to improve reliability in patient safety.

 

“If you don’t standardize, the rest is just chaos,” he said. “We have to make it easy to do these things.”

Dr. Meuthing said improving process reliability is key to reducing adverse outcomes, and high reliability organizations have utilized this approach to reduce serious harm events across the 81 SPS hospitals. While prevention of patient harm is the goal, an additional benefit is cost savings. He estimated $27 million of cost savings was realized within SPS network hospitals in 2012-2013.

Oral abstract and conundrum presentations, concurrent with 23 sessions across nine tracks, kept attendees busy. Topics ranged from a PHM circumcision service to decreasing overuse of continuous pulse oximetry. The day’s talks wrapped up with the respective presidents of the meeting’s co-sponsors—the American Academy of Pediatrics, the American Pediatrics Association, and SHM—sharing their organizations’ visions of PHM’s future in a town hall format.

The second full day began with an update of the Joint Council of Pediatric Hospital Medicine’s efforts to further advance PHM as a field. The process of submitting a petition to the American Board of Pediatrics was reviewed, as were the current status and time course of the move toward Accreditation Council for Graduate Medical Education certification.

After lunch, the highly anticipated “Top Articles” session was presented by Robert Dudas, MD, medical director of the pediatric hospitalist program at Johns Hopkins Bayview Medical Center in Baltimore, and Karen Wilson, MD, MPH, section head for pediatric hospital medicine at Children’s Hospital Colorado in Aurora. The presenters reviewed literature from the past year on topics ranging from nebulized hypertonic saline for bronchiolitis to antibiotic prophylaxis in vesicoureteral reflux.

The final day commenced with a talk by Alberto Puig, MD, PhD, FACP, associate director of undergraduate education at Massachusetts General Hospital in Boston, whose experiences as an internist provided insight regarding the history of the physical examination, from the aphorisms of Hippocrates to the family-centered bedside rounding of today.

---

Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.

Dr. O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

Dr. Hale is a past member of Team Hospitalist and a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Surrounded by the bucolic grounds of the Disney Yacht and Beach Club Resort in Lake Buena Vista, Fla., more than 800 pediatric hospitalists gathered in July for Pediatric Hospital Medicine 2014 (PHM14). Preceded by the Society for Pediatric Sedation’s pre-course, PHM14 began in earnest with a warm welcome from Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs at St. Louis (Mo.) Children’s Hospital and chair of the PHM14 organizing committee.

The first day of the conference started with Patrick Conway, MD, MSc, FAAP, MHM, chief medical officer for the Centers for Medicare and Medicaid Services (CMS), who gave an update of ongoing reforms in the U.S. health delivery system, with a focus on pediatrics. With three years of experience as CMS’ top doc, Dr. Conway related the difficulties of going from an unsustainable fee-for-service system to a people-centered, outcomes-driven system.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement and population health.” This practice, he added, means that the six goals of the CMS Quality Strategy align well with ongoing efforts in PHM.

Despite the difficulties of instituting change in a system that handles $3 billion daily, Dr. Conway, formerly a pediatric hospitalist at Cincinnati Children’s Hospital, said he’s witnessed many signs of improvement in the CMS landscape. Preliminary data from 2012-2014, he said, have shown a 9% reduction in hospital-acquired conditions across all measures, and overall hospital utilization is “dropping like a rock.”

While “having a foot in the boat and a foot on the dock” has been difficult, the transition, through its alphabet soup of innovation programs, is now beginning to pay off. Giving providers a pathway through the changing landscape of risk, Dr. Conway said, is an ongoing priority.

Wrapping up the first day, three healthcare system CEOs took the stage to answer questions from the audience, with Mark Shen, MD, SFHM, president of Dell Children’s Medical Center of Central Texas in Austin, Texas, posing questions like a seasoned talk show host. Panel members included David J. Bailey, MD, MBA, president and CEO of the Nemours Foundation; Steve Narang, MD, MHCM, FAAP, CEO of Banner Good Samaritan Medical Center in Phoenix, Ariz.; and Jeff Sperring, MD, FAAP, president and CEO of Riley Hospital for Children at Indiana University Health in Indianapolis.

Questions were wide-ranging.

Q: How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

Q: What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds. …It depends on ACO penetration, whether quality or volume will be the driver over the next three to five years,” Dr. Narang said.

Q: If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. I don’t think we’re going to be at a point where certification will limit being a hospitalist anytime soon,” Dr. Shen said.

Q: What are the three most important things, from a CEO perspective, that a hospitalist should know?

“Know where your organization wants to go,” Dr. Sperring said.

The next day kicked off with an inspiring call to action by Steve Meuthing, MD, vice president for safety at Cincinnati Children’s Hospital Medical Center. He called on pediatric hospitalists to eliminate all serious harm from children’s hospitals in the U.S. As a part of the Children’s Hospitals’ Solutions for Patient Safety (SPS) network, an organization accounting for 25% of all children hospitalized in the U.S., Dr. Meuthing related the need to employ high reliability theory, along with operational and cultural changes, to improve reliability in patient safety.

 

“If you don’t standardize, the rest is just chaos,” he said. “We have to make it easy to do these things.”

Dr. Meuthing said improving process reliability is key to reducing adverse outcomes, and high reliability organizations have utilized this approach to reduce serious harm events across the 81 SPS hospitals. While prevention of patient harm is the goal, an additional benefit is cost savings. He estimated $27 million of cost savings was realized within SPS network hospitals in 2012-2013.

Oral abstract and conundrum presentations, concurrent with 23 sessions across nine tracks, kept attendees busy. Topics ranged from a PHM circumcision service to decreasing overuse of continuous pulse oximetry. The day’s talks wrapped up with the respective presidents of the meeting’s co-sponsors—the American Academy of Pediatrics, the American Pediatrics Association, and SHM—sharing their organizations’ visions of PHM’s future in a town hall format.

The second full day began with an update of the Joint Council of Pediatric Hospital Medicine’s efforts to further advance PHM as a field. The process of submitting a petition to the American Board of Pediatrics was reviewed, as were the current status and time course of the move toward Accreditation Council for Graduate Medical Education certification.

After lunch, the highly anticipated “Top Articles” session was presented by Robert Dudas, MD, medical director of the pediatric hospitalist program at Johns Hopkins Bayview Medical Center in Baltimore, and Karen Wilson, MD, MPH, section head for pediatric hospital medicine at Children’s Hospital Colorado in Aurora. The presenters reviewed literature from the past year on topics ranging from nebulized hypertonic saline for bronchiolitis to antibiotic prophylaxis in vesicoureteral reflux.

The final day commenced with a talk by Alberto Puig, MD, PhD, FACP, associate director of undergraduate education at Massachusetts General Hospital in Boston, whose experiences as an internist provided insight regarding the history of the physical examination, from the aphorisms of Hippocrates to the family-centered bedside rounding of today.

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Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.

Dr. O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

Dr. Hale is a past member of Team Hospitalist and a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Clinical question: What is the incidence of hospital-acquired venous thromboembolism (HA-VTE), and which children are at the highest risk?

Background: The incidence of HA-VTE in adults is well documented and has led to extensive efforts to implement a risk-stratified approach to mechanical and pharmacologic prophylaxis. Studies of HA-VTE incidence in children have shown variability in observed incidence depending on the setting (community vs. tertiary care), rate of central venous catheter (CVC) use, and rate of underlying chronic conditions. Overall, as the incidence of HA-VTE has risen dramatically over the past decade, hospitalized children have become increasingly complex and have been subjected to increasing CVC placement. As in adults, pediatric VTE is associated with increased in-hospital mortality and can be associated with post-thrombotic syndrome.

Study design: Single-center, retrospective chart review.

Setting: 205-bed urban tertiary-care children’s hospital.

Synopsis: Using ICD-9 codes associated with deep vein thrombosis and pulmonary embolism, researchers identified potential cases of VTE over a 15-year period. Chart review confirmed the diagnosis of VTE if positive findings were found on compression ultrasound with duplex Doppler, CT angiography, MR venography, or conventional venography, or if the risk of PE was high probability on ventilation-perfusion scans. VTE was defined as hospital acquired if signs, symptoms, and diagnosis of VTE occurred after two days of hospitalization or if VTE was diagnosed ≤90 days after hospital discharge. ICD-9 codes were also used to identify complex chronic conditions (CCCs) and trauma.

Among the 90,485 patient admissions over this time period, 238 patients and 270 episodes of HA-VTE were identified in patients who were ≤21 years old. This yielded a composite rate of 0.3%, but only a 0.2% rate for patients diagnosed during hospitalization. Certain populations manifested a higher rate of HA-VTE. Compared to children two to nine years old, eight-fold higher rates were observed in older adolescents (14-17 years) and young adults (18-21 years), primarily due to non-CVC-associated VTE.

Bottom line: Despite an overall low incidence of hospital-acquired VTE in children under 21 years of age, certain CCCs, such as renal and cardiac diagnoses, were associated with much higher rates. Increasing age, medical complexity, and CVCs were also associated with a higher rate of VTE in the hospital.

Citation: Takemoto CM, Sohi S, Desai K, et al. Hospital-associated venous thromboembolism in children: incidence and clinical characteristics. J Pediatr. 2014;164(2):332-338.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the incidence of hospital-acquired venous thromboembolism (HA-VTE), and which children are at the highest risk?

Background: The incidence of HA-VTE in adults is well documented and has led to extensive efforts to implement a risk-stratified approach to mechanical and pharmacologic prophylaxis. Studies of HA-VTE incidence in children have shown variability in observed incidence depending on the setting (community vs. tertiary care), rate of central venous catheter (CVC) use, and rate of underlying chronic conditions. Overall, as the incidence of HA-VTE has risen dramatically over the past decade, hospitalized children have become increasingly complex and have been subjected to increasing CVC placement. As in adults, pediatric VTE is associated with increased in-hospital mortality and can be associated with post-thrombotic syndrome.

Study design: Single-center, retrospective chart review.

Setting: 205-bed urban tertiary-care children’s hospital.

Synopsis: Using ICD-9 codes associated with deep vein thrombosis and pulmonary embolism, researchers identified potential cases of VTE over a 15-year period. Chart review confirmed the diagnosis of VTE if positive findings were found on compression ultrasound with duplex Doppler, CT angiography, MR venography, or conventional venography, or if the risk of PE was high probability on ventilation-perfusion scans. VTE was defined as hospital acquired if signs, symptoms, and diagnosis of VTE occurred after two days of hospitalization or if VTE was diagnosed ≤90 days after hospital discharge. ICD-9 codes were also used to identify complex chronic conditions (CCCs) and trauma.

Among the 90,485 patient admissions over this time period, 238 patients and 270 episodes of HA-VTE were identified in patients who were ≤21 years old. This yielded a composite rate of 0.3%, but only a 0.2% rate for patients diagnosed during hospitalization. Certain populations manifested a higher rate of HA-VTE. Compared to children two to nine years old, eight-fold higher rates were observed in older adolescents (14-17 years) and young adults (18-21 years), primarily due to non-CVC-associated VTE.

Bottom line: Despite an overall low incidence of hospital-acquired VTE in children under 21 years of age, certain CCCs, such as renal and cardiac diagnoses, were associated with much higher rates. Increasing age, medical complexity, and CVCs were also associated with a higher rate of VTE in the hospital.

Citation: Takemoto CM, Sohi S, Desai K, et al. Hospital-associated venous thromboembolism in children: incidence and clinical characteristics. J Pediatr. 2014;164(2):332-338.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the incidence of hospital-acquired venous thromboembolism (HA-VTE), and which children are at the highest risk?

Background: The incidence of HA-VTE in adults is well documented and has led to extensive efforts to implement a risk-stratified approach to mechanical and pharmacologic prophylaxis. Studies of HA-VTE incidence in children have shown variability in observed incidence depending on the setting (community vs. tertiary care), rate of central venous catheter (CVC) use, and rate of underlying chronic conditions. Overall, as the incidence of HA-VTE has risen dramatically over the past decade, hospitalized children have become increasingly complex and have been subjected to increasing CVC placement. As in adults, pediatric VTE is associated with increased in-hospital mortality and can be associated with post-thrombotic syndrome.

Study design: Single-center, retrospective chart review.

Setting: 205-bed urban tertiary-care children’s hospital.

Synopsis: Using ICD-9 codes associated with deep vein thrombosis and pulmonary embolism, researchers identified potential cases of VTE over a 15-year period. Chart review confirmed the diagnosis of VTE if positive findings were found on compression ultrasound with duplex Doppler, CT angiography, MR venography, or conventional venography, or if the risk of PE was high probability on ventilation-perfusion scans. VTE was defined as hospital acquired if signs, symptoms, and diagnosis of VTE occurred after two days of hospitalization or if VTE was diagnosed ≤90 days after hospital discharge. ICD-9 codes were also used to identify complex chronic conditions (CCCs) and trauma.

Among the 90,485 patient admissions over this time period, 238 patients and 270 episodes of HA-VTE were identified in patients who were ≤21 years old. This yielded a composite rate of 0.3%, but only a 0.2% rate for patients diagnosed during hospitalization. Certain populations manifested a higher rate of HA-VTE. Compared to children two to nine years old, eight-fold higher rates were observed in older adolescents (14-17 years) and young adults (18-21 years), primarily due to non-CVC-associated VTE.

Bottom line: Despite an overall low incidence of hospital-acquired VTE in children under 21 years of age, certain CCCs, such as renal and cardiac diagnoses, were associated with much higher rates. Increasing age, medical complexity, and CVCs were also associated with a higher rate of VTE in the hospital.

Citation: Takemoto CM, Sohi S, Desai K, et al. Hospital-associated venous thromboembolism in children: incidence and clinical characteristics. J Pediatr. 2014;164(2):332-338.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: Do rapid response systems (RRS) reduce the rate of critical deterioration (CD) in hospitalized children?

Background: Over the past decade, a majority of pediatric inpatient units and freestanding children’s hospitals have instituted RRSs that utilize medical emergency teams (MET) to rapidly evaluate clinically deteriorating patients. Pediatric RRSs manifest variability between institutions in MET composition and RRS triggers. Prior studies of RRSs in the pediatric population have been mixed, with a lack of robust evidence that RRSs reduce hospital mortality and cardiopulmonary arrest rates. Evaluation of the effect of RRSs in pediatric units and hospitals is complicated by the heterogeneity of pediatric RRS implementation and the overall low rate of in-hospital cardiopulmonary arrest and death. In a 2012 study, the authors defined CD events as those leading to ICU transfer and subsequent mechanical ventilation (noninvasive or invasive) or vasopressor infusion within 12 hours. CD event rates, quantified as an event rate per 1,000 non-ICU patient-days, were found to be associated with a >13-fold increase in risk of in-hospital death and were believed to be a valid proximate outcome for in-hospital mortality.

Study design: Single-center interrupted time series analysis

Setting: 516-bed urban, tertiary care, freestanding children’s hospital.

Synopsis: The RRS at this institution consisted of an aggregate early warning score (EWS), which triggered the response of a MET (within 30 minutes) 24 hours a day, seven days a week. Distinct from the code-blue team, the MET comprised PICU staff, including: (1) a fellow, attending, or nurse practitioner; (2) a nurse; and (3) a respiratory therapist. Researchers compared the 32 months prior to implementation to the 27 months after implementation. An interrupted time series analysis was performed using advanced statistical modeling with adjustments for season, ward, and case-mix index.

Although there were no significant differences in rates of cardiopulmonary arrest or mortality, adjusted analysis revealed a net 62% reduction in CD event rate (IRR=0.38) after initiation of the RRS. Adjusted analysis also found a net 83% reduction in mechanical ventilation events (IRR=0.17) and a net 80% reduction in vasopressor use (IRR=0.20). Of note, these reductions were not significant in the unadjusted analyses. After transfer to the ICU, time elapsed until initiation of either mechanical ventilation or vasopressor use was longer.

Bottom line: With an aggregate EWS identifying high-risk patients requiring rapid evaluation by a MET, a pediatric RRS reduces adjusted rates of CD events but might not yield significant reductions in unadjusted rates of mortality, cardiopulmonary arrest, or CD events.

Citation: Bonafide CP, Localio AR, Roberts KE, Nadkarni VM, Weirich CM, Keren R. Impact of rapid response system imple-mentation on critical deterioration events in children. JAMA Pediatr. 2014;168(1):25-33.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: Do rapid response systems (RRS) reduce the rate of critical deterioration (CD) in hospitalized children?

Background: Over the past decade, a majority of pediatric inpatient units and freestanding children’s hospitals have instituted RRSs that utilize medical emergency teams (MET) to rapidly evaluate clinically deteriorating patients. Pediatric RRSs manifest variability between institutions in MET composition and RRS triggers. Prior studies of RRSs in the pediatric population have been mixed, with a lack of robust evidence that RRSs reduce hospital mortality and cardiopulmonary arrest rates. Evaluation of the effect of RRSs in pediatric units and hospitals is complicated by the heterogeneity of pediatric RRS implementation and the overall low rate of in-hospital cardiopulmonary arrest and death. In a 2012 study, the authors defined CD events as those leading to ICU transfer and subsequent mechanical ventilation (noninvasive or invasive) or vasopressor infusion within 12 hours. CD event rates, quantified as an event rate per 1,000 non-ICU patient-days, were found to be associated with a >13-fold increase in risk of in-hospital death and were believed to be a valid proximate outcome for in-hospital mortality.

Study design: Single-center interrupted time series analysis

Setting: 516-bed urban, tertiary care, freestanding children’s hospital.

Synopsis: The RRS at this institution consisted of an aggregate early warning score (EWS), which triggered the response of a MET (within 30 minutes) 24 hours a day, seven days a week. Distinct from the code-blue team, the MET comprised PICU staff, including: (1) a fellow, attending, or nurse practitioner; (2) a nurse; and (3) a respiratory therapist. Researchers compared the 32 months prior to implementation to the 27 months after implementation. An interrupted time series analysis was performed using advanced statistical modeling with adjustments for season, ward, and case-mix index.

Although there were no significant differences in rates of cardiopulmonary arrest or mortality, adjusted analysis revealed a net 62% reduction in CD event rate (IRR=0.38) after initiation of the RRS. Adjusted analysis also found a net 83% reduction in mechanical ventilation events (IRR=0.17) and a net 80% reduction in vasopressor use (IRR=0.20). Of note, these reductions were not significant in the unadjusted analyses. After transfer to the ICU, time elapsed until initiation of either mechanical ventilation or vasopressor use was longer.

Bottom line: With an aggregate EWS identifying high-risk patients requiring rapid evaluation by a MET, a pediatric RRS reduces adjusted rates of CD events but might not yield significant reductions in unadjusted rates of mortality, cardiopulmonary arrest, or CD events.

Citation: Bonafide CP, Localio AR, Roberts KE, Nadkarni VM, Weirich CM, Keren R. Impact of rapid response system imple-mentation on critical deterioration events in children. JAMA Pediatr. 2014;168(1):25-33.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: Do rapid response systems (RRS) reduce the rate of critical deterioration (CD) in hospitalized children?

Background: Over the past decade, a majority of pediatric inpatient units and freestanding children’s hospitals have instituted RRSs that utilize medical emergency teams (MET) to rapidly evaluate clinically deteriorating patients. Pediatric RRSs manifest variability between institutions in MET composition and RRS triggers. Prior studies of RRSs in the pediatric population have been mixed, with a lack of robust evidence that RRSs reduce hospital mortality and cardiopulmonary arrest rates. Evaluation of the effect of RRSs in pediatric units and hospitals is complicated by the heterogeneity of pediatric RRS implementation and the overall low rate of in-hospital cardiopulmonary arrest and death. In a 2012 study, the authors defined CD events as those leading to ICU transfer and subsequent mechanical ventilation (noninvasive or invasive) or vasopressor infusion within 12 hours. CD event rates, quantified as an event rate per 1,000 non-ICU patient-days, were found to be associated with a >13-fold increase in risk of in-hospital death and were believed to be a valid proximate outcome for in-hospital mortality.

Study design: Single-center interrupted time series analysis

Setting: 516-bed urban, tertiary care, freestanding children’s hospital.

Synopsis: The RRS at this institution consisted of an aggregate early warning score (EWS), which triggered the response of a MET (within 30 minutes) 24 hours a day, seven days a week. Distinct from the code-blue team, the MET comprised PICU staff, including: (1) a fellow, attending, or nurse practitioner; (2) a nurse; and (3) a respiratory therapist. Researchers compared the 32 months prior to implementation to the 27 months after implementation. An interrupted time series analysis was performed using advanced statistical modeling with adjustments for season, ward, and case-mix index.

Although there were no significant differences in rates of cardiopulmonary arrest or mortality, adjusted analysis revealed a net 62% reduction in CD event rate (IRR=0.38) after initiation of the RRS. Adjusted analysis also found a net 83% reduction in mechanical ventilation events (IRR=0.17) and a net 80% reduction in vasopressor use (IRR=0.20). Of note, these reductions were not significant in the unadjusted analyses. After transfer to the ICU, time elapsed until initiation of either mechanical ventilation or vasopressor use was longer.

Bottom line: With an aggregate EWS identifying high-risk patients requiring rapid evaluation by a MET, a pediatric RRS reduces adjusted rates of CD events but might not yield significant reductions in unadjusted rates of mortality, cardiopulmonary arrest, or CD events.

Citation: Bonafide CP, Localio AR, Roberts KE, Nadkarni VM, Weirich CM, Keren R. Impact of rapid response system imple-mentation on critical deterioration events in children. JAMA Pediatr. 2014;168(1):25-33.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the appropriate length of hospitalization necessary for infants <30 days admitted for fever without source?

Background: Infants ≤30 days old are routinely hospitalized for fever without source (FWS). From 1988-2006, 2.5 million infants younger than three months old were admitted for sepsis, according to National Hospital Discharge Survey data. Term infants <7 days of age accounted for 33% of these hospitalizations. Current national guidelines recommend observation in the hospital for 48-72 hours after cultures of blood, urine, and cerebrospinal fluid (CSF) are initiated. Whether this length of hospitalization is appropriate for well-appearing infants in this age group is not clear, based on current data.

Study design: Single-center, retrospective, cohort study.

Setting: 574-bed tertiary medical center with a 30-bed general pediatric inpatient unit.

Synopsis: Researchers identified infants ≤30 days old who had blood and/or CSF cultures performed from 1999 to 2010. After excluding infants with cultures from the NICU and PICU, infants hospitalized with FWS were identified by chart review. A pediatric infectious disease specialist reviewed positive cultures from blood and CSF to exclude skin contaminants. Time to notification was defined as the time between sample collection and medical staff notification. Blood cultures were monitored continuously for growth at this institution, with staff being notified of positive results immediately during the day but not until 8 a.m. if this occurred overnight. Microbiology laboratory staff reviewed CSF cultures once daily. Of the 408 confirmed FWS hospitalizations, 26 resulted in positive cultures of blood and/or CSF. Time to notification of >24 hours occurred in six of these hospitalizations. Overall, of the 388 FWS hospitalizations with no positive blood or CSF cultures at 24 hours, six went on to develop positive cultures after 24 hours, a rate of 1.5%. All six had at least one high-risk characteristic (WBC <5,000 or >15,000 per µL, a band count >1,500 per per µL, or abnormal urinalysis). However, five patients with no high-risk characteristics and a normal urinalysis on admission were diagnosed with a UTI after 24 hours.

Bottom line: Infants ≤30 days old with no high-risk characteristics for sepsis may not need a full 48 hours of hospitalization for FWS, although this approach could lead rarely to a diagnosis of UTI after discharge.

Citation: Fielding-Singh V, Hong DK, Harris SJ, et al. Ruling out bacteremia and bacterial meningitis in infants less than one month of age: is 48 hours of hospitalization necessary? Hosp Pediatrics. 2013;3(4):355-361.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the appropriate length of hospitalization necessary for infants <30 days admitted for fever without source?

Background: Infants ≤30 days old are routinely hospitalized for fever without source (FWS). From 1988-2006, 2.5 million infants younger than three months old were admitted for sepsis, according to National Hospital Discharge Survey data. Term infants <7 days of age accounted for 33% of these hospitalizations. Current national guidelines recommend observation in the hospital for 48-72 hours after cultures of blood, urine, and cerebrospinal fluid (CSF) are initiated. Whether this length of hospitalization is appropriate for well-appearing infants in this age group is not clear, based on current data.

Study design: Single-center, retrospective, cohort study.

Setting: 574-bed tertiary medical center with a 30-bed general pediatric inpatient unit.

Synopsis: Researchers identified infants ≤30 days old who had blood and/or CSF cultures performed from 1999 to 2010. After excluding infants with cultures from the NICU and PICU, infants hospitalized with FWS were identified by chart review. A pediatric infectious disease specialist reviewed positive cultures from blood and CSF to exclude skin contaminants. Time to notification was defined as the time between sample collection and medical staff notification. Blood cultures were monitored continuously for growth at this institution, with staff being notified of positive results immediately during the day but not until 8 a.m. if this occurred overnight. Microbiology laboratory staff reviewed CSF cultures once daily. Of the 408 confirmed FWS hospitalizations, 26 resulted in positive cultures of blood and/or CSF. Time to notification of >24 hours occurred in six of these hospitalizations. Overall, of the 388 FWS hospitalizations with no positive blood or CSF cultures at 24 hours, six went on to develop positive cultures after 24 hours, a rate of 1.5%. All six had at least one high-risk characteristic (WBC <5,000 or >15,000 per µL, a band count >1,500 per per µL, or abnormal urinalysis). However, five patients with no high-risk characteristics and a normal urinalysis on admission were diagnosed with a UTI after 24 hours.

Bottom line: Infants ≤30 days old with no high-risk characteristics for sepsis may not need a full 48 hours of hospitalization for FWS, although this approach could lead rarely to a diagnosis of UTI after discharge.

Citation: Fielding-Singh V, Hong DK, Harris SJ, et al. Ruling out bacteremia and bacterial meningitis in infants less than one month of age: is 48 hours of hospitalization necessary? Hosp Pediatrics. 2013;3(4):355-361.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the appropriate length of hospitalization necessary for infants <30 days admitted for fever without source?

Background: Infants ≤30 days old are routinely hospitalized for fever without source (FWS). From 1988-2006, 2.5 million infants younger than three months old were admitted for sepsis, according to National Hospital Discharge Survey data. Term infants <7 days of age accounted for 33% of these hospitalizations. Current national guidelines recommend observation in the hospital for 48-72 hours after cultures of blood, urine, and cerebrospinal fluid (CSF) are initiated. Whether this length of hospitalization is appropriate for well-appearing infants in this age group is not clear, based on current data.

Study design: Single-center, retrospective, cohort study.

Setting: 574-bed tertiary medical center with a 30-bed general pediatric inpatient unit.

Synopsis: Researchers identified infants ≤30 days old who had blood and/or CSF cultures performed from 1999 to 2010. After excluding infants with cultures from the NICU and PICU, infants hospitalized with FWS were identified by chart review. A pediatric infectious disease specialist reviewed positive cultures from blood and CSF to exclude skin contaminants. Time to notification was defined as the time between sample collection and medical staff notification. Blood cultures were monitored continuously for growth at this institution, with staff being notified of positive results immediately during the day but not until 8 a.m. if this occurred overnight. Microbiology laboratory staff reviewed CSF cultures once daily. Of the 408 confirmed FWS hospitalizations, 26 resulted in positive cultures of blood and/or CSF. Time to notification of >24 hours occurred in six of these hospitalizations. Overall, of the 388 FWS hospitalizations with no positive blood or CSF cultures at 24 hours, six went on to develop positive cultures after 24 hours, a rate of 1.5%. All six had at least one high-risk characteristic (WBC <5,000 or >15,000 per µL, a band count >1,500 per per µL, or abnormal urinalysis). However, five patients with no high-risk characteristics and a normal urinalysis on admission were diagnosed with a UTI after 24 hours.

Bottom line: Infants ≤30 days old with no high-risk characteristics for sepsis may not need a full 48 hours of hospitalization for FWS, although this approach could lead rarely to a diagnosis of UTI after discharge.

Citation: Fielding-Singh V, Hong DK, Harris SJ, et al. Ruling out bacteremia and bacterial meningitis in infants less than one month of age: is 48 hours of hospitalization necessary? Hosp Pediatrics. 2013;3(4):355-361.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Quality Improvement

A computerized pathway for managing patients with chronic obstructive pulmonary disease (COPD), described in a Research, Innovations, and Clinical Vignettes poster/abstract presented at HM13, brings together evidence-based computerized physician order entry order sets for managing COPD with links to pulmonology and respiratory therapy protocols, and with established care transitions processes at the University of California at San Diego.¹

“When I started this journey, examining how we were doing in adhering to national and international guidelines for COPD care, it turned out we were not doing such a great job,” says lead author Weijen Chang, MD, SFHM, FAAP, who works as a med-peds hospitalist at UCSD and is pediatric editor of The Hospitalist. “We were providing ideal care as defined in the guidelines only about 60 percent of the time.”

Dr. Chang found that UCSD pulmonologists were simultaneously working on their own QI project, so they combined forces around a COPD Inpatient Care Workgroup comprising hospitalists, pulmonologists, respiratory therapists, pharmacists, and information system specialists. The group developed a COPD Longitudinal Inpatient Pathway and Transition Pathway (CLIPT) addressing appropriate referrals for subspecialist care and rehabilitation in and out of the hospital.

The key was not just to create order sets for optimal COPD care, but also to improve access, continuity of care, and post-discharge follow-up through the pathway, which is available for initiation in the ED, at or after admission, or at discharge, Dr. Chang explains. Transition nurse specialists trained as part of a separate initiative at the medical center provide COPD case management. The group is exploring the use of respiratory therapists to actively case-manage COPD patients going home. Patients are connected with a COPD discharge clinic staffed part-time by a UCSD pulmonologist.

According to the abstract, the CLIPT pathway was initiated in 46% of patients admitted with acute exacerbations of COPD. Dr. Chang says further study is needed to assess outcomes during and after hospitalization.

More ideas on enhancing hospital care for the COPD population in order to manage their high risk of readmissions was presented at the recent COPD and Readmissions Summit sponsored by the COPD Foundation (www.copdfoundation.org) in October in Washington, D.C.

 

References

1. Chang W, Maynard G, Clay B. Implementation of a computerized COPD inpatient pathway and transition pathway [abstract]. J Hosp Med. 2013;8 Suppl 1:709.
2. Schmitt S, McQuillen DP, Nahass R, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs [published online ahead of print September 25, 2013]. Clin Infect Dis.
3. Torio CM, Andrews RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. Healthcare Cost and Utilization Project Statistical Brief #160. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.jsp. Accessed October 26, 2013.
4. Herman B. Top 20 most expensive inpatient conditions. Becker’s Hospital Review. Oct. 9, 2013. Available at: http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/top-20-most-expensive-inpatient-conditions.html. Accessed October 26, 2013.

Quality Improvement

A computerized pathway for managing patients with chronic obstructive pulmonary disease (COPD), described in a Research, Innovations, and Clinical Vignettes poster/abstract presented at HM13, brings together evidence-based computerized physician order entry order sets for managing COPD with links to pulmonology and respiratory therapy protocols, and with established care transitions processes at the University of California at San Diego.¹

“When I started this journey, examining how we were doing in adhering to national and international guidelines for COPD care, it turned out we were not doing such a great job,” says lead author Weijen Chang, MD, SFHM, FAAP, who works as a med-peds hospitalist at UCSD and is pediatric editor of The Hospitalist. “We were providing ideal care as defined in the guidelines only about 60 percent of the time.”

Dr. Chang found that UCSD pulmonologists were simultaneously working on their own QI project, so they combined forces around a COPD Inpatient Care Workgroup comprising hospitalists, pulmonologists, respiratory therapists, pharmacists, and information system specialists. The group developed a COPD Longitudinal Inpatient Pathway and Transition Pathway (CLIPT) addressing appropriate referrals for subspecialist care and rehabilitation in and out of the hospital.

The key was not just to create order sets for optimal COPD care, but also to improve access, continuity of care, and post-discharge follow-up through the pathway, which is available for initiation in the ED, at or after admission, or at discharge, Dr. Chang explains. Transition nurse specialists trained as part of a separate initiative at the medical center provide COPD case management. The group is exploring the use of respiratory therapists to actively case-manage COPD patients going home. Patients are connected with a COPD discharge clinic staffed part-time by a UCSD pulmonologist.

According to the abstract, the CLIPT pathway was initiated in 46% of patients admitted with acute exacerbations of COPD. Dr. Chang says further study is needed to assess outcomes during and after hospitalization.

More ideas on enhancing hospital care for the COPD population in order to manage their high risk of readmissions was presented at the recent COPD and Readmissions Summit sponsored by the COPD Foundation (www.copdfoundation.org) in October in Washington, D.C.

 

References

1. Chang W, Maynard G, Clay B. Implementation of a computerized COPD inpatient pathway and transition pathway [abstract]. J Hosp Med. 2013;8 Suppl 1:709.
2. Schmitt S, McQuillen DP, Nahass R, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs [published online ahead of print September 25, 2013]. Clin Infect Dis.
3. Torio CM, Andrews RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. Healthcare Cost and Utilization Project Statistical Brief #160. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.jsp. Accessed October 26, 2013.
4. Herman B. Top 20 most expensive inpatient conditions. Becker’s Hospital Review. Oct. 9, 2013. Available at: http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/top-20-most-expensive-inpatient-conditions.html. Accessed October 26, 2013.

Quality Improvement

A computerized pathway for managing patients with chronic obstructive pulmonary disease (COPD), described in a Research, Innovations, and Clinical Vignettes poster/abstract presented at HM13, brings together evidence-based computerized physician order entry order sets for managing COPD with links to pulmonology and respiratory therapy protocols, and with established care transitions processes at the University of California at San Diego.¹

“When I started this journey, examining how we were doing in adhering to national and international guidelines for COPD care, it turned out we were not doing such a great job,” says lead author Weijen Chang, MD, SFHM, FAAP, who works as a med-peds hospitalist at UCSD and is pediatric editor of The Hospitalist. “We were providing ideal care as defined in the guidelines only about 60 percent of the time.”

Dr. Chang found that UCSD pulmonologists were simultaneously working on their own QI project, so they combined forces around a COPD Inpatient Care Workgroup comprising hospitalists, pulmonologists, respiratory therapists, pharmacists, and information system specialists. The group developed a COPD Longitudinal Inpatient Pathway and Transition Pathway (CLIPT) addressing appropriate referrals for subspecialist care and rehabilitation in and out of the hospital.

The key was not just to create order sets for optimal COPD care, but also to improve access, continuity of care, and post-discharge follow-up through the pathway, which is available for initiation in the ED, at or after admission, or at discharge, Dr. Chang explains. Transition nurse specialists trained as part of a separate initiative at the medical center provide COPD case management. The group is exploring the use of respiratory therapists to actively case-manage COPD patients going home. Patients are connected with a COPD discharge clinic staffed part-time by a UCSD pulmonologist.

According to the abstract, the CLIPT pathway was initiated in 46% of patients admitted with acute exacerbations of COPD. Dr. Chang says further study is needed to assess outcomes during and after hospitalization.

More ideas on enhancing hospital care for the COPD population in order to manage their high risk of readmissions was presented at the recent COPD and Readmissions Summit sponsored by the COPD Foundation (www.copdfoundation.org) in October in Washington, D.C.

 

References

1. Chang W, Maynard G, Clay B. Implementation of a computerized COPD inpatient pathway and transition pathway [abstract]. J Hosp Med. 2013;8 Suppl 1:709.
2. Schmitt S, McQuillen DP, Nahass R, et al. Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs [published online ahead of print September 25, 2013]. Clin Infect Dis.
3. Torio CM, Andrews RM. National inpatient hospital costs: the most expensive conditions by payer, 2011. Healthcare Cost and Utilization Project Statistical Brief #160. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.jsp. Accessed October 26, 2013.
4. Herman B. Top 20 most expensive inpatient conditions. Becker’s Hospital Review. Oct. 9, 2013. Available at: http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/top-20-most-expensive-inpatient-conditions.html. Accessed October 26, 2013.

Clinical question: What is the benefit of oseltamivir treatment to previously healthy children hospitalized with confirmed influenza infection?

Background: Influenza is generally a mild, self-limited infection that affects all ages but can lead to more serious illness. During the 2012-2013 season, laboratory-confirmed influenza in children zero to four years was associated with a hospitalization rate of 66.4 per 100,000 and 164 pediatric deaths. Currently, the American Academy of Pediatrics and the CDC recommend treatment with either oseltamivir or zanamivir for children hospitalized with influenza. However, despite the recommendations, data are limited regarding the benefits resulting from treating otherwise healthy children hospitalized with influenza.

Study design: Multi-center retrospective study.

Setting: Ten public hospitals in Madrid, Spain, between September 2010 and June 2012.

Synopsis: Researchers identified children ≤14 years admitted to participating hospitals by positive testing with either rapid diagnostic testing or polymerase chain reaction assay of nasal washings. Patients at high risk of serious disease were excluded, including those with chronic disease, immunodeficiency, prematurity (less than 32 weeks gestation), age less than six months at admission, nosocomial infection, and those requiring ICU-level care upon admission. Patients with asthma were included. Decision to treat with oseltamivir was determined by hospital guidelines, with some hospitals treating all hospitalized children with confirmed influenza and others only treating patients with risk factors for severe disease. In addition, only children who had manifested symptoms within 48 hours of admission were included.

Of the 287 children included in the final analysis, 93 were treated with oseltamivir (32%). There were no significant differences between treatment and non-treatment groups in duration of fever, duration of hypoxia, length of stay, or rates of ICU transfer. In addition, the lack of differences in outcomes persisted after subgroup analysis of patients less than one year old.

Bottom line: Treatment with oseltamivir of otherwise healthy children hospitalized with influenza not requiring ICU care is unlikely to yield measurable benefit.

Citation: Bueno M, Calvo C, Mendez-Echevarría A, et al. Oseltamivir treatment for influenza in hospitalized children without underlying diseases. Pediatr Infect Dis J. 2013;32(10):1066-1069.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the benefit of oseltamivir treatment to previously healthy children hospitalized with confirmed influenza infection?

Background: Influenza is generally a mild, self-limited infection that affects all ages but can lead to more serious illness. During the 2012-2013 season, laboratory-confirmed influenza in children zero to four years was associated with a hospitalization rate of 66.4 per 100,000 and 164 pediatric deaths. Currently, the American Academy of Pediatrics and the CDC recommend treatment with either oseltamivir or zanamivir for children hospitalized with influenza. However, despite the recommendations, data are limited regarding the benefits resulting from treating otherwise healthy children hospitalized with influenza.

Study design: Multi-center retrospective study.

Setting: Ten public hospitals in Madrid, Spain, between September 2010 and June 2012.

Synopsis: Researchers identified children ≤14 years admitted to participating hospitals by positive testing with either rapid diagnostic testing or polymerase chain reaction assay of nasal washings. Patients at high risk of serious disease were excluded, including those with chronic disease, immunodeficiency, prematurity (less than 32 weeks gestation), age less than six months at admission, nosocomial infection, and those requiring ICU-level care upon admission. Patients with asthma were included. Decision to treat with oseltamivir was determined by hospital guidelines, with some hospitals treating all hospitalized children with confirmed influenza and others only treating patients with risk factors for severe disease. In addition, only children who had manifested symptoms within 48 hours of admission were included.

Of the 287 children included in the final analysis, 93 were treated with oseltamivir (32%). There were no significant differences between treatment and non-treatment groups in duration of fever, duration of hypoxia, length of stay, or rates of ICU transfer. In addition, the lack of differences in outcomes persisted after subgroup analysis of patients less than one year old.

Bottom line: Treatment with oseltamivir of otherwise healthy children hospitalized with influenza not requiring ICU care is unlikely to yield measurable benefit.

Citation: Bueno M, Calvo C, Mendez-Echevarría A, et al. Oseltamivir treatment for influenza in hospitalized children without underlying diseases. Pediatr Infect Dis J. 2013;32(10):1066-1069.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the benefit of oseltamivir treatment to previously healthy children hospitalized with confirmed influenza infection?

Background: Influenza is generally a mild, self-limited infection that affects all ages but can lead to more serious illness. During the 2012-2013 season, laboratory-confirmed influenza in children zero to four years was associated with a hospitalization rate of 66.4 per 100,000 and 164 pediatric deaths. Currently, the American Academy of Pediatrics and the CDC recommend treatment with either oseltamivir or zanamivir for children hospitalized with influenza. However, despite the recommendations, data are limited regarding the benefits resulting from treating otherwise healthy children hospitalized with influenza.

Study design: Multi-center retrospective study.

Setting: Ten public hospitals in Madrid, Spain, between September 2010 and June 2012.

Synopsis: Researchers identified children ≤14 years admitted to participating hospitals by positive testing with either rapid diagnostic testing or polymerase chain reaction assay of nasal washings. Patients at high risk of serious disease were excluded, including those with chronic disease, immunodeficiency, prematurity (less than 32 weeks gestation), age less than six months at admission, nosocomial infection, and those requiring ICU-level care upon admission. Patients with asthma were included. Decision to treat with oseltamivir was determined by hospital guidelines, with some hospitals treating all hospitalized children with confirmed influenza and others only treating patients with risk factors for severe disease. In addition, only children who had manifested symptoms within 48 hours of admission were included.

Of the 287 children included in the final analysis, 93 were treated with oseltamivir (32%). There were no significant differences between treatment and non-treatment groups in duration of fever, duration of hypoxia, length of stay, or rates of ICU transfer. In addition, the lack of differences in outcomes persisted after subgroup analysis of patients less than one year old.

Bottom line: Treatment with oseltamivir of otherwise healthy children hospitalized with influenza not requiring ICU care is unlikely to yield measurable benefit.

Citation: Bueno M, Calvo C, Mendez-Echevarría A, et al. Oseltamivir treatment for influenza in hospitalized children without underlying diseases. Pediatr Infect Dis J. 2013;32(10):1066-1069.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the yield of blood cultures performed on pediatric patients admitted for uncomplicated and complicated skin and soft tissue infections (SSTIs and cSSTIs)?

Background: SSTIs are a common cause of pediatric ED visits and hospitalizations. Current Infectious Diseases Society of America (IDSA) guidelines include obtaining a blood culture for patients who show signs of systemic toxicity. Blood cultures are performed frequently in all pediatric patients hospitalized for SSTI and cSSTI. Little recent data exists about the rate of bacteremia in pediatric SSTI since the widespread emergence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and adoption of routine vaccination for Haemophilus influenzae type B (HiB) and varicella.

Study design: Single-center, retrospective case series.

Setting: University-affiliated pediatric hospital at a tertiary medical center.

Synopsis: Researchers used the hospital’s electronic medical record system to search for patients between the ages of 0 and 18 years hospitalized for SSTI/cSSTI. Initial screening of the data utilized ICD-9-CM codes for cellulitis and abscess (682.X), with subsequent review by investigators to exclude miscoded cases, immunocompromised patients, hospital-acquired infection, and incidentally noted SSTI during admissions for other problems. SSTIs were classified as being complicated in the cases of surgical or traumatic wound infection, need for surgical intervention, and infected ulcers or burns. Routine incision and drainage did not constitute surgical intervention.

Of the 580 patients remaining, 482 were classified as having SSTI, of which 455 underwent testing with blood cultures. None of the blood cultures led to pathogenic bacterial growth after 120 hours of incubation; three grew S. epidermidis. Of the 98 patients classified as having cSSTI, 80 underwent blood culture testing, of which 10 (12.5%) were positive.

Pathogens identified in positive blood cultures included MRSA (6), methicillin-sensitive S. aureus (3), and S. pneumococcus (1). Length of stay was significantly longer for patients with SSTI who underwent blood culture testing (3.24 days) compared to those who did not (2.33 days).

Bottom line: Obtaining blood cultures in a child hospitalized with uncomplicated SSTI is highly unlikely to be helpful in obtaining a bacteriologic diagnosis. Even worse, it will likely increase the length of stay for these patients.

Citation: Malone JR, Durica SR, Thompson DM, Bogie A, Naifeh M. Blood cultures in the evaluation of uncomplicated skin and soft tissue infections. Pediatrics. 2013;132:454-459.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the yield of blood cultures performed on pediatric patients admitted for uncomplicated and complicated skin and soft tissue infections (SSTIs and cSSTIs)?

Background: SSTIs are a common cause of pediatric ED visits and hospitalizations. Current Infectious Diseases Society of America (IDSA) guidelines include obtaining a blood culture for patients who show signs of systemic toxicity. Blood cultures are performed frequently in all pediatric patients hospitalized for SSTI and cSSTI. Little recent data exists about the rate of bacteremia in pediatric SSTI since the widespread emergence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and adoption of routine vaccination for Haemophilus influenzae type B (HiB) and varicella.

Study design: Single-center, retrospective case series.

Setting: University-affiliated pediatric hospital at a tertiary medical center.

Synopsis: Researchers used the hospital’s electronic medical record system to search for patients between the ages of 0 and 18 years hospitalized for SSTI/cSSTI. Initial screening of the data utilized ICD-9-CM codes for cellulitis and abscess (682.X), with subsequent review by investigators to exclude miscoded cases, immunocompromised patients, hospital-acquired infection, and incidentally noted SSTI during admissions for other problems. SSTIs were classified as being complicated in the cases of surgical or traumatic wound infection, need for surgical intervention, and infected ulcers or burns. Routine incision and drainage did not constitute surgical intervention.

Of the 580 patients remaining, 482 were classified as having SSTI, of which 455 underwent testing with blood cultures. None of the blood cultures led to pathogenic bacterial growth after 120 hours of incubation; three grew S. epidermidis. Of the 98 patients classified as having cSSTI, 80 underwent blood culture testing, of which 10 (12.5%) were positive.

Pathogens identified in positive blood cultures included MRSA (6), methicillin-sensitive S. aureus (3), and S. pneumococcus (1). Length of stay was significantly longer for patients with SSTI who underwent blood culture testing (3.24 days) compared to those who did not (2.33 days).

Bottom line: Obtaining blood cultures in a child hospitalized with uncomplicated SSTI is highly unlikely to be helpful in obtaining a bacteriologic diagnosis. Even worse, it will likely increase the length of stay for these patients.

Citation: Malone JR, Durica SR, Thompson DM, Bogie A, Naifeh M. Blood cultures in the evaluation of uncomplicated skin and soft tissue infections. Pediatrics. 2013;132:454-459.

---

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What is the yield of blood cultures performed on pediatric patients admitted for uncomplicated and complicated skin and soft tissue infections (SSTIs and cSSTIs)?

Background: SSTIs are a common cause of pediatric ED visits and hospitalizations. Current Infectious Diseases Society of America (IDSA) guidelines include obtaining a blood culture for patients who show signs of systemic toxicity. Blood cultures are performed frequently in all pediatric patients hospitalized for SSTI and cSSTI. Little recent data exists about the rate of bacteremia in pediatric SSTI since the widespread emergence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and adoption of routine vaccination for Haemophilus influenzae type B (HiB) and varicella.

Study design: Single-center, retrospective case series.

Setting: University-affiliated pediatric hospital at a tertiary medical center.

Synopsis: Researchers used the hospital’s electronic medical record system to search for patients between the ages of 0 and 18 years hospitalized for SSTI/cSSTI. Initial screening of the data utilized ICD-9-CM codes for cellulitis and abscess (682.X), with subsequent review by investigators to exclude miscoded cases, immunocompromised patients, hospital-acquired infection, and incidentally noted SSTI during admissions for other problems. SSTIs were classified as being complicated in the cases of surgical or traumatic wound infection, need for surgical intervention, and infected ulcers or burns. Routine incision and drainage did not constitute surgical intervention.

Of the 580 patients remaining, 482 were classified as having SSTI, of which 455 underwent testing with blood cultures. None of the blood cultures led to pathogenic bacterial growth after 120 hours of incubation; three grew S. epidermidis. Of the 98 patients classified as having cSSTI, 80 underwent blood culture testing, of which 10 (12.5%) were positive.

Pathogens identified in positive blood cultures included MRSA (6), methicillin-sensitive S. aureus (3), and S. pneumococcus (1). Length of stay was significantly longer for patients with SSTI who underwent blood culture testing (3.24 days) compared to those who did not (2.33 days).

Bottom line: Obtaining blood cultures in a child hospitalized with uncomplicated SSTI is highly unlikely to be helpful in obtaining a bacteriologic diagnosis. Even worse, it will likely increase the length of stay for these patients.

Citation: Malone JR, Durica SR, Thompson DM, Bogie A, Naifeh M. Blood cultures in the evaluation of uncomplicated skin and soft tissue infections. Pediatrics. 2013;132:454-459.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What are the characteristics of children who died in children’s hospitals while receiving palliative care (PC) compared to those who did not?

Background: Approximately 44,000 children die annually in hospitals in the U.S. Since the American Academy of Pediatrics (AAP) released a statement in August 2000 that presented an integrated model for providing PC to children with life-threatening conditions, pediatric PC programs have increased steadily in number. Children who receive PC services are commonly afflicted by genetic/congenital disorders, neuromuscular disorders, and cancer diagnoses. Although it is estimated that 6,320 people under the age of 24 received PC services in 2010, little data exist comparing pediatric inpatients receiving PC and those who do not.

Study design: Multicenter retrospective cohort study.

Setting: More than 40 freestanding children’s hospitals.

Synopsis: Using the Pediatric Health Information System (PHIS) database, which collects administrative and clinical data from more than 40 freestanding children’s hospitals belonging to the Children’s Hospital Association, researchers analyzed the characteristics of children under the age of 18 who died in the hospital more than five days after admission from 2001 to 2011. They extracted demographic data and categorized patients using major diagnostic categories (MDC) based on major organ system or etiology of disease. Identification of patients receiving PC services was by ICD-9 codes, and utilization of medications and procedures was identified by clinical transaction codes (CTC) and ICD-9 codes. The unit billing the last hospital day determined location of death.

Of the 24,342 children studied, only 3.8% received PC services based on coding. Patients less likely to receive PC services included black children (2.3%), those with circulatory diseases (2.8%), and those with neonatal diseases (1.9%). Children who did receive PC services had a significantly lower median length of stay (17 vs. 21 days), average daily charges ($9,348 vs. $11,806), received significantly fewer interventions (mechanical ventilation, invasive monitoring, surgical procedures), and died less frequently in an ICU setting (60% vs. 88%). PC services disproportionately altered the care of children with lymphatic/hematopoietic diseases, significantly decreasing use of mechanical ventilation (75% to 22%) and death in an ICU setting (66% to 21%).

Bottom line: Provision of PC services to children dying in children’s hospitals remains low. It is even lower for children with certain racial backgrounds and disease processes. When provided, PC services reduce length of stay, average daily charges, invasive procedures, and death in an ICU setting.

Citation: Keele L, Keenan HT, Sheetz J. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132(1):72-78.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What are the characteristics of children who died in children’s hospitals while receiving palliative care (PC) compared to those who did not?

Background: Approximately 44,000 children die annually in hospitals in the U.S. Since the American Academy of Pediatrics (AAP) released a statement in August 2000 that presented an integrated model for providing PC to children with life-threatening conditions, pediatric PC programs have increased steadily in number. Children who receive PC services are commonly afflicted by genetic/congenital disorders, neuromuscular disorders, and cancer diagnoses. Although it is estimated that 6,320 people under the age of 24 received PC services in 2010, little data exist comparing pediatric inpatients receiving PC and those who do not.

Study design: Multicenter retrospective cohort study.

Setting: More than 40 freestanding children’s hospitals.

Synopsis: Using the Pediatric Health Information System (PHIS) database, which collects administrative and clinical data from more than 40 freestanding children’s hospitals belonging to the Children’s Hospital Association, researchers analyzed the characteristics of children under the age of 18 who died in the hospital more than five days after admission from 2001 to 2011. They extracted demographic data and categorized patients using major diagnostic categories (MDC) based on major organ system or etiology of disease. Identification of patients receiving PC services was by ICD-9 codes, and utilization of medications and procedures was identified by clinical transaction codes (CTC) and ICD-9 codes. The unit billing the last hospital day determined location of death.

Of the 24,342 children studied, only 3.8% received PC services based on coding. Patients less likely to receive PC services included black children (2.3%), those with circulatory diseases (2.8%), and those with neonatal diseases (1.9%). Children who did receive PC services had a significantly lower median length of stay (17 vs. 21 days), average daily charges ($9,348 vs. $11,806), received significantly fewer interventions (mechanical ventilation, invasive monitoring, surgical procedures), and died less frequently in an ICU setting (60% vs. 88%). PC services disproportionately altered the care of children with lymphatic/hematopoietic diseases, significantly decreasing use of mechanical ventilation (75% to 22%) and death in an ICU setting (66% to 21%).

Bottom line: Provision of PC services to children dying in children’s hospitals remains low. It is even lower for children with certain racial backgrounds and disease processes. When provided, PC services reduce length of stay, average daily charges, invasive procedures, and death in an ICU setting.

Citation: Keele L, Keenan HT, Sheetz J. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132(1):72-78.

---

Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.

Clinical question: What are the characteristics of children who died in children’s hospitals while receiving palliative care (PC) compared to those who did not?

Background: Approximately 44,000 children die annually in hospitals in the U.S. Since the American Academy of Pediatrics (AAP) released a statement in August 2000 that presented an integrated model for providing PC to children with life-threatening conditions, pediatric PC programs have increased steadily in number. Children who receive PC services are commonly afflicted by genetic/congenital disorders, neuromuscular disorders, and cancer diagnoses. Although it is estimated that 6,320 people under the age of 24 received PC services in 2010, little data exist comparing pediatric inpatients receiving PC and those who do not.

Study design: Multicenter retrospective cohort study.

Setting: More than 40 freestanding children’s hospitals.

Synopsis: Using the Pediatric Health Information System (PHIS) database, which collects administrative and clinical data from more than 40 freestanding children’s hospitals belonging to the Children’s Hospital Association, researchers analyzed the characteristics of children under the age of 18 who died in the hospital more than five days after admission from 2001 to 2011. They extracted demographic data and categorized patients using major diagnostic categories (MDC) based on major organ system or etiology of disease. Identification of patients receiving PC services was by ICD-9 codes, and utilization of medications and procedures was identified by clinical transaction codes (CTC) and ICD-9 codes. The unit billing the last hospital day determined location of death.

Of the 24,342 children studied, only 3.8% received PC services based on coding. Patients less likely to receive PC services included black children (2.3%), those with circulatory diseases (2.8%), and those with neonatal diseases (1.9%). Children who did receive PC services had a significantly lower median length of stay (17 vs. 21 days), average daily charges ($9,348 vs. $11,806), received significantly fewer interventions (mechanical ventilation, invasive monitoring, surgical procedures), and died less frequently in an ICU setting (60% vs. 88%). PC services disproportionately altered the care of children with lymphatic/hematopoietic diseases, significantly decreasing use of mechanical ventilation (75% to 22%) and death in an ICU setting (66% to 21%).

Bottom line: Provision of PC services to children dying in children’s hospitals remains low. It is even lower for children with certain racial backgrounds and disease processes. When provided, PC services reduce length of stay, average daily charges, invasive procedures, and death in an ICU setting.

Citation: Keele L, Keenan HT, Sheetz J. Differences in characteristics of dying children who receive and do not receive palliative care. Pediatrics. 2013;132(1):72-78.

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Reviewed by Pediatric Editor Weijen Chang, MD, SFHM, FAAP, associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine, and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital.