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
This study features a single center, nested, case-control design that looked retrospectively at 542 children aged 2-24 months who presented to the ED from January 2007 to April 2013 with fever and had a catheterized urinalysis obtained. Patients were then matched with randomly selected children without a UTI to create a training database. Five models using different variables were developed, including one with only clinical characteristics and four that combined clinical characteristics with differing laboratory values. The area under the curve of the “clinical model” was 0.80, while those of the remaining four models ranged from 0.97 to 0.98. The clinical model showed a sensitivity of 95% and specificity of 35% in the training database, while the four other models showed sensitivities ranging from 93% to 96% and specificities ranging from 91% to 93%. The models were then validated using a cohort of children aged 2-24 months who presented to the ED with fever from July 2015 to December 2016; the UTI prevalence in this cohort was 7.8%. Finally, using a hypothetical cohort of 1,000 children being evaluated for a UTI, the authors showed that UTICalc reduced the numbers of urine samples obtained by 8.1% and missed UTIs from 3 to 0 compared with following AAP guidelines.5
Limitations
The training database was created retrospectively at a single institution and is subject to local practice patterns. The proposed calculator creates an algorithm that is meant to be used in a setting where the pretest probability for a UTI is reasonably high based on criteria from the AAP UTI guidelines.
Important Findings and Implications
UTICalc could be a great tool for providers to guide testing for UTIs in children aged 2-24 months presenting with a fever. Given further study at multiple sites and settings, including outpatient clinics, UTICalc could have significant implications for reducing unnecessary testing and treatment in febrile children.
Lost Earnings and Nonmedical Expenses of Pediatric Hospitalizations. Chang LV, et al. Pediatrics. 2018;142(3):e20180195.6
Background
Although medical expenses related to hospitalization can be significant for many families, nonmedical costs, such as transportation, parking, meals, and lost earnings from missed days at work, are also important to consider. These hardships can lead to challenges in postdischarge follow-up and adherence to discharge instructions, both of which lead to hospital readmissions. This article presents a cross-sectional analysis at a large, free-standing children’s hospital that participated in the Hospital-to-Home Outcomes Study (H2O). The authors sought to determine whether families with more financial or social hardships are affected disproportionately by nonmedical costs related to hospitalizations.
Study Overview and Results
A total of 1,372 children were included and children with lengths of stay >13 days were excluded. Face-to-face parental surveys were conducted and included questions on parental education, employment status, sick leave flexibility, and measures of financial and social hardship. The study authors calculated a total cost burden (TCB) based on nonmedical costs estimated at the time of the survey, including lost wages and expenses during the hospitalization. A daily cost burden (DCB) based on length of hospital stay and daily cost burden as a percentage of daily income (DCBi) were also calculated. The median TCB was $112.80, and the median DCB was $51.40. The median DCBi showed that the median household had 45% of their daily income depleted by nonmedical expenses related to their hospitalization. Those who reported more financial or social hardships had a higher median DCBi; if ≥3 financial hardships were reported, 86% of the daily household income was depleted.
