Updates in Pediatric Hospital Medicine: Six Practical Ways to Improve the Care of Hospitalized Children
BACKGROUND: As pediatric hospital medicine continues to grow, it is important to keep abreast of the current literature. This article provides a summary of six of the most impactful articles published in 2018.
METHODS: The authors reviewed articles published between January 2018 and December 2018 for the 2019 Society of Hospital Medicine national conference presentation of Top Articles in Pediatric Hospital Medicine, where the top 10 articles of 2018 were presented. Six of the 10 articles are highlighted in this review based on article quality and their applicability to change practices in the hospital setting or prompt further research.
RESULTS: Key findings from the articles include: multiple interventions aimed at providers can improve compliance with bronchiolitis guidelines; a developed calculator can improve testing for urinary tract infections in children aged 2-24 months; nonmedical costs of hospitalizations are underappreciated and disproportionately affect those with a lower socioeconomic status; a progress note template in an electronic health record can lead to higher quality and shorter notes; for febrile infants aged 60 days and younger, most blood and cerebrospinal fluid culture pathogens can be identified within 24 hours and nearly all by 36 hours; and the development of a high-value care tool can help to bring concepts of high-value care into family-centered rounds.
CONCLUSION: The six selected articles highlight findings pertinent to pediatric hospital medicine.
© 2019 Society of Hospital Medicine
Study Overview and Results
This project took place at a free-standing children’s hospital and included urgent care locations. Authors obtained pre-intervention data through two bronchiolitis seasons in 2013 and 2014 for patients aged 1-23 months with a primary or secondary diagnosis of bronchiolitis and who did not require admission to the Intensive Care Unit (ICU). The intervention period was from December 2015 to April 2016. All sites simultaneously implemented their interventions, which included education of care team members and families, updated order sets, and electronic health record (EHR)-generated e-mails that provided data looking at peer ranking statistics for each intervention, CXR, RVT, and bronchodilator usage. A data dashboard was created to display real-time utilization of the studied interventions. Providers were also asked to sign a pledge that they would reduce unnecessary testing and treatment. As balancing measures, the numbers of patients presenting to the Emergency Room (ER) or readmitted within seven days of an ED visit or admission for bronchiolitis were tracked; patients who required ICU levels of care during their first admission or on readmission were also tracked. Statistically significant decreases in CXR ordering from 39.5% to 27.2%, RVT ordering from 31.9% to 26.3%, and any bronchodilator usage from 34.2% to 21.5% were noted. No difference pre- and postintervention in patients readmitted to the ICU was found, and length of stay (LOS) between groups was not statistically significant.
Limitations
As all interventions were initiated simultaneously, identifying which individual or subset of interventions was responsible for changing provider behavior was impossible. More patients postintervention were admitted under observation status and under a milder All Patient Refined Diagnosis Related Groups (APR DRGs) severity index, which may indicate a less-sick cohort of patients in this group. Since the LOS and number of patients readmitted to the ICU were similar in both groups, it is unlikely that the postintervention group represented a less-sick cohort.
Important Findings and Implications
This QI project highlighted novel ways to implement and emphasize the importance of compliance to CPG. A provider pledge may be helpful in reinforcing to all providers the idea that the institution is committed to guideline implementation. Comparing individual provider data and having a real-time dashboard with group performance can help reinforce goals and progress toward them at the group, site, and individual patient population levels.
Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children. Shaikh N, et al. JAMA Pediatrics. 2018;172(6):550-556.3
Background
The prevalence of urinary tract infections (UTIs) in children under 2 years of age that present to the emergency department (ED) with fever is about 7%.4 After clinical examination, providers obtaining a urinalysis must then determine if empirical antibiotics are warranted for a suspected UTI. This study describes the development of a novel calculator, UTICalc that estimates the pretest probability of a UTI based on clinical findings and the posttest probability of a UTI based on laboratory results.
