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
Limitations
The study was conducted at a single institution with a number of existing support systems in place to help unburden families of hospitalized children. Non-English-speaking families were excluded. A face-to-face survey may have influenced parental responses regarding social and financial hardships.
Important Findings and Implications
Nonmedical costs of hospitalized children can be quantified and disproportionately affect those experiencing financial and social hardships. Hospitalists should be aware of these findings and find ways within their hospital systems to provide support for families both during and after hospitalizations.
A Prescription for Note Bloat: An Effective Progress Note Template. Kahn D, et al. Journal of Hospital Medicine. 2018;13(6):378-382.7
Background
Although electronic health records (EHRs) have improved the speed and legibility of documentation, the harm of “note bloat,” defined as multiple pages of nonessential information which leaves key aspects buried or lost, is prevalent. In this prospective, quality improvement study across four internal medicine residency programs, the authors investigated a bundled intervention consisting of didactic teaching and an electronic progress note template on note quality, length, and timeliness.
Study overview and results
Notes pre- and postintervention were graded using a tool that considered the general impression of the note, its score on the validated Physician Documentation Quality Instrument (PDQI-9),8 and a questionnaire based on the Accreditation Council for Graduate Medical Education competency note checklist.9 Analyzing 200 preintervention and 199 postintervention notes, significant improvement was seen in general impression scores, all PDQI-9 domains, and 6 of 13 note competency questionnaire items. The mean number of lines in the note decreased by 25%, and the mean completion time when the note was signed was 1 hour and 15 minutes earlier. The greatest impact on shortening notes involved a reduction in the auto-population of laboratory and imaging studies.
Limitations
The study was unblinded. The authors attempted to minimize bias with an objective questionnaire and employed multiple graders per note; however, poor interrater reliability was obtained. Postintervention, 70% of all residents used the template. At one of the four institutions, evidence of note quality improvement despite low template use was found. At another institution, no improvement in note quality was reported despite relatively high template uptake. Local culture and institutional buy-in may be factors affecting these results. In addition, pre- and postintervention notes were examined in the same academic year; thus, the effects seen may be due, in part, to resident maturation. Generalizability to nonacademic institutions and the durability of the intervention are additional concerns.
Important Findings and Implications
Resident education on documentation and an EHR progress note template incorporating best practices can effectively combat “note bloat” and lead to higher quality and shorter notes that are completed earlier in the day. This solution has significant implications for improving transitions of care, handoffs, and patient safety.
