The hospitalization of a child is a stressful event for the child and family. The physician responsible for the admission has an important role in directing the care of the child, communicating with the child’s providers (medical and primary caregivers), and advocating for the safety of the child during the hospitalization and transition out of the hospital. These challenges remain constant across the varied facilities in which children are hospitalized. The purpose of this revised clinical report is to update pediatricians about principles to improve the coordination of care and review expectations and practice.
BACKGROUND AND OBJECTIVES: Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months. METHODS: We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children’s hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures. RESULTS: The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found. CONCLUSIONS: Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.
BACKGROUND AND OBJECTIVES: The Value in Inpatient Pediatrics Network sponsored the Improving Care in Community Acquired Pneumonia collaborative with the goal of increasing evidence-based management of children hospitalized with community acquired pneumonia (CAP). Project aims included: increasing use of narrow-spectrum antibiotics, decreasing use of macrolides, and decreasing concurrent treatment of pneumonia and asthma. METHODS: Data were collected through chart review across emergency department (ED), inpatient, and discharge settings. Sites reviewed up to 20 charts in each of 6 3-month cycles. Analysis of means with 3-σ control limits was the primary method of assessment for change. The expert panel developed project measures, goals, and interventions. A change package of evidence-based tools to promote judicious use of antibiotics and raise awareness of asthma and pneumonia codiagnosis was disseminated through webinars. Peer coaching and periodic benchmarking were used to motivate change. RESULTS: Fifty-three hospitals enrolled and 48 (91%) completed the 1-year project (July 2014–June 2015). A total of 3802 charts were reviewed for the project; 1842 during baseline cycles and 1960 during postintervention cycles. The median before and after use of narrow-spectrum antibiotics in the collaborative increased by 67% in the ED, 43% in the inpatient setting, and 25% at discharge. Median before and after use of macrolides decreased by 22% in the ED and 27% in the inpatient setting. A decrease in asthma and CAP codiagnosis was noted, but the change was not sustained. CONCLUSIONS: Low-cost strategies, including collaborative sharing, peer benchmarking, and coaching, increased judicious use of antibiotics in a diverse range of hospitals for pediatric CAP.
BACKGROUND AND OBJECTIVE: Children with community-acquired lower respiratory tract infection (CA-LRTI) commonly receive antibiotics for Mycoplasma pneumoniae. The objective was to evaluate the effect of treating M. pneumoniae in children with CA-LRTI. METHODS: PubMed, Cochrane Central Register of Controlled Trials, and bibliography review. A search was conducted by using Medical Subject Headings terms related to CA-LRTI and M. pneumoniae and was not restricted by language. Eligible studies included randomized controlled trials (RCTs) and observational studies of children ≤17 years old with confirmed M. pneumoniae and a diagnosis of CA-LRTI; each must have also compared treatment regimens with and without spectrum of activity against M. pneumoniae. Data extraction and quality assessment were completed independently by multiple reviewers before arriving at a consensus. Data were pooled using a random effects model. RESULTS: Sixteen articles detailing 17 studies were included. The most commonly selected primary outcome was symptomatic improvement. Nine studies examined M. pneumoniae treatment in CA-LRTI secondary to M. pneumoniae, and 5 RCTs met criteria for meta-analysis. The suggested pooled risk difference of 0.12 (95% confidence interval, −0.04 to 0.20) favoring treatment was not significantly different and demonstrated significant heterogeneity. Limitations included substantial bias and subjective outcomes within the individual studies, difficulty interpreting testing modalities, and the inability to correct for mixed infections or timing of intervention. CONCLUSIONS: We identified insufficient evidence to support or refute treatment of M. pneumoniae in CA-LRTI. These data highlight the need for well-designed, prospective RCTs assessing the effect of treating M. pneumoniae in CA-LRTI.
BACKGROUND: Fever in infants is a common clinical dilemma. The objective of this study was to present data from hospital systems across the northeast, southeast, mid-west, and western United States to identify the pathogens causing bacteremia in febrile infants admitted to general care units. METHODS: This was a retrospective review of positive blood culture results in febrile infants aged ≤90 days admitted to a general care unit across 6 hospital systems. Data were collected from January 1, 2006 through December 31, 2012 from emergency departments and general inpatient units. Cultures from ICUs, central lines, or infants who had complex comorbidities were excluded, as were repeat cultures positive for the same bacteria. Common contaminants were considered pathogens if they were treated as such. RESULTS: We identified 181 cases of bacteremia in 177 infants. The most common pathogen was Escherichia coli (42%), followed by group B Streptococcus (23%). Streptococcus pneumoniae was more likely in older infants (P = .01). Non-low-risk bacteremic infants were more likely to have E coli or group B Streptococcus than low-risk bacteremic infants. We identified no cases of Listeria monocytogenes. Variation between sites was minimal. CONCLUSIONS: This is the largest and most geographically diverse study to date examining the epidemiology of bacteremia in infants. We suggest E coli is the most common cause of bacteremia in previously healthy febrile infants admitted to a general inpatient unit. We identified no cases of L monocytogenes and question whether empirical therapy remains necessary for this pathogen.