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Top Ten Articles in Pediatric Hospital Medicine: Breaking Traditions :

September 5, 2018

Every year at the annual Pediatric Hospital Medicine (PHM) Conference, a selection of articles are highlighted as the “Top 10 Articles” in Hospital Medicine.

Every year at the annual Pediatric Hospital Medicine (PHM) Conference, a selection of articles are highlighted as the “Top 10 Articles” in Hospital Medicine. This plenary has been one of the most popular and well-attended sessions since the conference’s inception. The intention of this plenary is to present articles that are the most impactful and meaningful for improving the care for hospitalized pediatric patients. We independently reviewed abstracts published from July 2017 through June 2018 from 18 peer-reviewed clinical journals relevant to PHM. Ultimately, we selected 10 articles based on generalizability, thought-provoking content, game-changing results, methodologic rigor, and relevant topics.  Many of these articles exemplify pediatric hospitalist expertise in novel approaches to management in clinical areas such as pneumonia, febrile infants, and newborn care.


Topic 1: Newborn Care

Efficacy of subthreshold newborn phototherapy during the birth hospitalization in preventing readmission for phototherapy 

Authors assessed the impact on readmissions when using phototherapy for newborns with bilirubin levels slightly below the AAP guidelines for phototherapy.  Although the readmission rate for patients who received subthreshold phototherapy was lower (5% compared to 13%) than infants who did not receive phototherapy during the birth hospitalization, the number needed to treat to avoid 1 readmission was around 14.  Additionally, subthreshold phototherapy was associated with a 22 hour longer length of stay.

Impact to practice: Although preventing readmission in 1 of every 14 infants treated, sub-threshold phototherapy extends length of stay, increases resource utilization, and may pose challenges to early maternal bonding.

A novel approach to assessing infants with neonatal abstinence syndrome

These authors developed a functional based assessment tool for infants with neonatal abstinence syndrome (NAS) called the Eat, Sleep and Console (ESC) method, and compared morphine utilization in 50 consecutive opioid exposed infants with the ESC method to the  traditional Finnegan Scale.  Using the ESC method, 12% of infants were treated with morphine, translating into 87.2% morphine free days and an ALOS of 5.9 compared to 62% of infants treated with morphine (52.7% morphine free days) and an ALOS of 16 days if the Finnegan strategy had been used. There were no adverse events including seizures, transfer to the intensive care unit (ICU) or readmissions. 

Impact to Practice: Newer functional based assessments may prevent unnecessary morphine administration and decrease LOS without adverse events.  

Accuracy of complete blood cell counts to identify febrile infants 60 days or younger with invasive bacterial infections

This study was a secondary analysis of a prospectively enrolled cohort of febrile infants 60 days and younger seen at 26 emergency departments. Using receiver operating curves, authors measured test accuracy for WBC counts, ANC and platelet counts in determining invasive bacterial illness using the area under the curve (AUC).  Only 2% of infants (n-97) in the large cohort had invasive bacterial illness.  The WBC count AUC was fairly low – 0.57 (95% CI, 0.50-0.63) – indicating a poorly accurate test and similar to flipping a coin in terms of accuracy.  The authors found similar results for both the ANC and platelet counts. 

Impact to Practice:   Although limited by the small number of cases in a large cohort, this study questions the utility of the CBC as part of the febrile infant diagnostic evaluation and risk stratification.


Topic 2: Pneumonialitis

Effectiveness of beta-lactam monotherapy vs macrolide combination therapy for children hospitalized with pneumonia.

In this multicenter, prospective, population-based study of children hospitalized with community-acquired pneumonia, children <18 years of age with radiographically confirmed pneumonia were stratified into two treatment arms: β-lactam monotherapy versus β-lactam + macrolide. The primary outcome was length of stay (LOS) and secondary outcomes included ICU admissions, re-hospitalizations, and self-reported recovery at follow-up. Of the 1418 children in the unmatched cohort and 560 children in the propensity scored matching cohort, there was no difference in LOS or secondary outcomes.

Impact to Practice:  Most children admitted to the hospital with community acquired pneumonia are unlikely to benefit from the addition of a macrolide. The harms of dual treatment likely outweigh the benefits.

Nebulised hypertonic saline solution for acute bronchiolitis in infants

This Cochrane Database Review sought to determine if hypertonic saline (HS) decreases hospital LOS in bronchiolitis. Using random-effects modelling, the authors undertook a meta-analysis on 28 randomized controlled and quasi-controlled trials.  On primary analysis, the use of HS compared to normal saline demonstrated a shortened LOS by -0.41 days (95% confidence interval (CI) -0.75 to -0.07). However, on subgroup analysis by hospitalization with a total LOS ≤ 3 days, more reflective of US hospitalizations for bronchiolitis, the effect size was 0.07 (95% CI: -0.29 to 0.44).

Impact to Practice:  #1. HS does not shorten LOS #2. Even though meta-analyses are at the top of the evidence based medicine pyramid, critical analysis of the literature is crucial to appropriate application to practice.  

Outcomes of follow-up visits after bronchiolitis hospitalizations

In this multicenter prospective study, families were contacted 5 to 8 days after hospital discharge for bronchiolitis and weekly thereafter until symptom resolution to assess for the occurrence and outcomes of any healthcare encounters, and parental perceptions of these follow-up visits. 112 families (66%) had at least 1 clinic visit within 8 days of discharge, and 95% of these families agreed or strongly agreed that the visit was “a good use of my or my family’s time.” When parents were asked which aspect of the visit was most useful, 73% parents reported that the “reassurance provided” was most useful. New treatments were uncommonly provided with only 13 prescriptions (8 for a breathing treatment, 2 for corticosteroids, and 7 for antibiotics).

Impact to Practice:  Routine visits after bronchiolitis hospitalization appear to provide many families with reassurance, but also may generate unnecessary further interventions. The need for follow-up visits ought to be determined on a case-by-case basis.


Topic 3: UTI

Development and validation of a calculator for estimating the probability of urinary tract infection in young febrile children

In this nested case-control study of febrile children 2 months to 2 years, authors developed multivariable logistic regression models to estimate the risk of a urinary tract infection (UTI) based on clinical and laboratory information, then embedded them into an online calculator The authors tested the UTIcalc’s estimation of risk against recommendations from the AAP UTI guidelines using a threshold of a 2% risk of UTI to recommend urine testing and 5% risk of UTI to recommend empiric antibiotics.  Tested in cohort of patients, the UTIcalc missed no cases of UTI, and recommended testing approximately 10 children for every 1 UTI detected, representing slight improvement over the AAP guidelines in number needed to test.

Impact to Practice: This calculator is a just-in-time tool to inform decision making around urine testing and empiric antibiotics, and may facilitate discussions with families to promote shared decision making.


Topic 4: Potpourri

Reducing electrolyte testing in hospitalized children by using quality improvement methods

In this quality improvement project aimed at decreasing electrolyte testing, authors assessed patient electrolyte testing/10 patient days, test results/10 patient days and testing charges.  Balancing measures included medical emergency team calls and readmission rates.  After serial PDSA cycles, authors showed a decrease in electrolyte laboratory draws from a mean of 2/10 patient days to 1.3/10 patient days, a 35% reduction in electrolyte testing, translating into a 50% decrease in overall volume of test results and overall cost reduction of around $300,000 with no significant changes in the balancing measures.

Impact to practice: Each reduction in lab draws, however small, may have improved the quality of life of an inpatient though fewer needle pokes – an unmeasured benefit - in addition to decreasing hospital cost in aggregate. While we should continue to focus on the high- cost items reductions, this study reminds us that improvement opportunities are everywhere no matter how small.


Topic 5: Complex Care

Development and validation of the pediatric medical complexity algorithm (PMCA) version 2.0

Development and validation of the pediatric medical complexity algorithm (PMCA) version 3.0

In 2014, the Pediatric Medical Complexity Algorithm (PMCA Version 1.0) was developed to use ICD-9 codes in Medicaid and hospital administrative data to stratify children by medical complexity into 3 groups: complex chronic disease, non-complex chronic disease, and those without chronic disease. In 2017, the authors refined PMCA Version 1.0 based on user feedback and further testing resulting in Version 2.0 and demonstrated variability in performance based on the duration of eligibility and completeness of Medicaid data. Subsequently in 2018, the authors undertook extensive chart review of ICD-10 codes to develop PMCA Version 3.0. This latest version resulted in similar performance in identifying children with complex chronic disease who have accessed tertiary hospitals with very good sensitivity and specificity when applied to hospital administrative data.

Impact to Practice:

This publicly available algorithm can be used by clinicians and researchers to identify children with complex chronic disease and target resources and services to those children most in need and to identify disparities in quality of care by level of medical complexity.


Topic 6: MED-ED

Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: A randomized clinical trial

In this randomized controlled trial using crossover study design of a general internal medical service at a large academic center, teams were divided into a “standard supervision” arm where attending physicians joined rounds for both newly admitted but not established patients and an “increased supervision arm” where attending physicians joined bedside rounds for both newly admitted AND established patients. The two main outcome measures were:  the rate of medical errors, and the impact on resident education. In total, 22 faculty participated with each faculty participating in both arms in random order. While there was no difference in overall medical errors, preventable adverse events, or near-misses between the two arms, increased supervision was associated with a decrease in the amount the interns spoke during rounds a perception of decreased autonomy among both senior residents and interns. Interestingly, attending physicians perceived the care of patients was improved when they were present on more rounds.

Impact to Practice: It is incumbent for each residency program and each attending to decide on the right balance of direct and indirect supervision on rounds.  As educators and clinicians, it is critical to consider patient safety both in the short term and the long term and to determine what the right mix of supervision is to assure safe and effective patient care now, while creating the space for learners to learn. 


References:

Cruz AT, Mahajan P, Bonsu BK, et al. Accuracy of complete blood cell counts to identify febrile infants 60 days or younger with invasive bacterial infections. JAMA Pediatr. 2017;171(11):e172927.

Finn KM, Metlay JP, Chang Y, et al. Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: A randomized clinical trial. JAMA Intern Med. 2018;178(7):952-959. 

Grossman MR, Lipshaw MJ, Osborn RR, Berkwitt AK. A novel approach to assessing infants with neonatal abstinence syndrome. Hosp Pediatr. 2018;8(1):1-6.

Schroeder AR, Destino LA, Brooks R, Wang CJ, Coon ER. Outcomes of follow-up visits after bronchiolitis hospitalizations. JAMA Pediatr. 2018;172(3):296-297.

Shaikh N, Hoberman A, Hum SW, et al. Development and validation of a calculator for estimating the probability of urinary tract infection in young febrile children. JAMA Pediatr. 2018;172(6):550-556.

Simon TD, Cawthon ML, Popalisky J, Mangione-Smith R, Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). Development and validation of the pediatric medical complexity algorithm (PMCA) version 2.0. Hosp Pediatr. 2017;7(7):373-377.

Simon TD, Haaland W, Hawley K, Lambka K, Mangione-Smith R. Development and validation of the pediatric medical complexity algorithm (PMCA) version 3.0. Acad Pediatr. 2018. 2018;18(5):577-580. 

Tchou MJ et al. Reducing electrolyte testing in hospitalized children by using quality improvement methods. Pediatrics. 2018;141(5):10.1542/peds.2017-3187.

Wickremasinghe AC, Kuzniewicz MW, McCulloch CE, Newman TB. Efficacy of subthreshold newborn phototherapy during the birth hospitalization in preventing readmission for phototherapy. JAMA Pediatr. 2018;172(4):378-385.

Williams DJ, Edwards KM, Self WH, et al. Effectiveness of beta-lactam monotherapy vs macrolide combination therapy for children hospitalized with pneumonia. JAMA Pediatr. 2017;171(12):1184-1191.

Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev. 2017;12:CD006458.

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