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
The routine evaluation of febrile infants aged ≤60 days old often involves blood and cerebrospinal (CSF) fluid evaluations, and many infants are hospitalized while waiting for culture results. A previous study of febrile infants showed that 91% of the pathogenic organisms could be identified on blood culture within 24 hours and that 96% could be identified within 36 hours; 81% of the bacterial pathogens present were detected on CSF culture within 36 hours.11
Study Overview and Results
In this large, multicenter study of infants presenting to the Emergency Departments (EDs) of 10 children’s hospitals over a five-year study period, the authors investigated the time to pathogen detection in blood and CSF for infants aged ≤60 days with bacteremia and/or bacterial meningitis; whether the time to detection differed for non-ill and ill infants was also examined. Ill- versus non-ill-appearance was determined by a medical record review of the physical exam looking for one of 13 key words (eg, “ill-appearing,” “toxic,” “lethargic,” etc.). A total of 381 infants were included. Overall, 88% of the pathogens present were detected in blood culture within 24 hours and 95% were detected within 36 hours. In CSF, 89% of the pathogens present were detected within 24 hours, and 95% were detected within 36 hours. In infants with bacteremia who were non-ill-appearing, 85% of the blood pathogens were detected within 24 hours.
Limitations
The median time to detection for blood culture pathogens for ill-appearing versus non-ill-appearing infants was shorter by just one hour, but 15% of the non-ill infants had a positive blood culture after 24 hours. However, the prevalence of bacteremia and meningitis in non-ill-appearing infants is likely low; the authors did not report the total number of febrile infants evaluated by EDs in the study.
Important Findings and Implications
Most positive blood and/or CSF cultures for infants aged ≤60 days will yield results by 24 hours; 95% of the pathogens present could be detected within 36 hours. Sending a non-ill-appearing febrile infant home at 24 hours may miss 15% of the instances of bacteremia, but the overall low prevalence of invasive bacterial infection in infants should be considered.
The High-Value Care Rounding Tool: Development and Validity Evidence. McDaniel CE, et al. Academic Medicine. 2018;93(2):199-206.12
Background
Providing high-value care (HVC) to patients is a struggle for physicians and healthcare systems. Although physicians teaching trainees HVC practices could be an effective way to increase cost-conscious care, the best practices for teaching HVC remain unknown. To fill this gap, the authors developed a tool to measure the frequency and content of observable HVC teaching and evaluated the validity of the tool within a pediatric inpatient setting.
Study Overview and Results
The HVC rounding tool was developed through several phases from conception to validation. The research group used a modified Delphi method to construct the tool using a consensus building process based on opinions from content experts in the field of HVC, from a variety of specialties, experience levels, and geographic areas of the United States. Each item of the HVC instrument was rated by these experts, and, from their evaluations and surveys, an 11-item HVC tool was constructed. A pilot of the tool was performed to establish internal validity and interrater reliability based on observations of 148 patient encounters. From this process, a final 10-item HVC rounding tool emerged, including domains in quality, cost, and patient values. A few items included giving positive feedback for not doing an unnecessary test, discussing whether a patient needs to stay inpatient or meets discharge criteria, and customizing a care plan to align with family values and goals. The final iteration of the tool had no rater disagreements within the quality and patient values domain and only one disagreement within the cost domain.
