Amanda C. Schondelmeyer

Variation in Care of the Febrile Young Infant <90 Days in US Pediatric Emergency Departments

BACKGROUND AND OBJECTIVES: Variation in patient care or outcomes may indicate an opportunity to improve quality of care. We evaluated the variation in testing, treatment, hospitalization rates, and outcomes of febrile young infants in US pediatric emergency departments (EDs). METHODS: Retrospective cohort study of infants <90 days of age with a diagnosis code of fever who were evaluated in 1 of 37 pediatric EDs between July 1, 2011 and June 30, 2013. We assessed patient- and hospital-level variation in testing, treatment, and disposition for patients in 3 distinct age groups: ≤28, 29 to 56, and 57 to 89 days. We also compared interhospital variation for 3-day revisits and revisits resulting in hospitalization. RESULTS: We identified 35 070 ED visits that met inclusion criteria. The proportion of patients who underwent comprehensive evaluation, defined as urine, serum, and cerebrospinal fluid testing, decreased with increasing patient age: 72.0% (95% confidence interval [CI], 71.0–73.0) of neonates ≤28 days, 49.0% (95% CI, 48.2–49.8) of infants 29 to 56 days, and 13.1% (95% CI, 12.5–13.6) of infants 57 to 89 days. Significant interhospital variation was demonstrated in testing, treatment, and hospitalization rates overall and across all 3 age groups, with little interhospital variation in outcomes. Hospitalization rate in the overall cohort did not correlate with 3-day revisits (R2 = 0.10, P = .06) or revisits resulting in hospitalization (R2 = 0.08, P = .09). CONCLUSIONS: Substantial patient- and hospital-level variation was observed in the ED management of the febrile young infant, without concomitant differences in outcomes. Strategies to understand and address the modifiable sources of variation are needed.

Using quality improvement to optimise paediatric discharge efficiency

Background Bed capacity management is a critical issue facing hospital administrators, and inefficient discharges impact patient flow throughout the hospital. National recommendations include a focus on providing care that is timely and efficient, but a lack of standardised discharge criteria at our institution contributed to unpredictable discharge timing and lengthy delays. Our objective was to increase the percentage of Hospital Medicine patients discharged within 2 h of meeting criteria from 42% to 80%. Methods A multidisciplinary team collaborated to develop medically appropriate discharge criteria for 11 common inpatient diagnoses. Discharge criteria were embedded into electronic medical record (EMR) order sets at admission and could be modified throughout a patients stay. Nurses placed an EMR time-stamp to signal when patients met all discharge goals. Strategies to improve discharge timeliness emphasised completion of discharge tasks prior to meeting criteria. Interventions focused on buy-in from key team members, pharmacy process redesign, subspecialty consult timeliness and feedback to frontline staff. A P statistical process control chart assessed the impact of interventions over time. Length of stay (LOS) and readmission rates before and after implementation of process measures were compared using the Wilcoxon rank-sum test. Results The percentage of patients discharged within 2 h significantly improved from 42% to 80% within 18 months. Patients studied had a decrease in median overall LOS (from 1.56 to 1.44 days; p=0.01), without an increase in readmission rates (4.60% to 4.21%; p=0.24). The 12-month rolling average census for the study units increased from 36.4 to 42.9, representing an 18% increase in occupancy. Conclusions Through standardising discharge goals and implementation of high-reliability interventions, we reduced LOS without increasing readmission rates.

Association of clinical practice guidelines with emergency department management of febrile infants ≤56 days of age

BACKGROUND Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increased healthcare costs. OBJECTIVE Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants. DESIGN Retrospective cross-sectional study in 2013. SETTING Thirty-three hospitals in the Pediatric Health Information System. PATIENTS Infants aged ≤56 days with a diagnosis of fever. EXPOSURES The presence and content of ED-based febrile infant CPGs assessed by electronic survey. MEASUREMENTS Using generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in 2 age groups: ≤28 days and 29 to 56 days. We also assessed CPG impact on healthcare costs. RESULTS We included 9377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29 to 56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (adjusted odds ratio: 0.5, 95% confidence interval: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29 to 56 days old at hospitals with CPGs. CONCLUSIONS CPG recommendations for febrile infants 29 to 56 days old vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs.

Accuracy of diagnosis codes to identify febrile young infants using administrative data

BACKGROUND Administrative data can be used to determine optimal management of febrile infants and aid clinical practice guideline development. OBJECTIVE Determine the most accurate International Classification of Diseases, Ninth Revision (ICD-9) diagnosis coding strategies for identification of febrile infants. DESIGN Retrospective cross-sectional study. SETTING Eight emergency departments in the Pediatric Health Information System. PATIENTS Infants aged <90 days evaluated between July 1, 2012 and June 30, 2013 were randomly selected for medical record review from 1 of 4 ICD-9 diagnosis code groups: (1) discharge diagnosis of fever, (2) admission diagnosis of fever without discharge diagnosis of fever, (3) discharge diagnosis of serious infection without diagnosis of fever, and (4) no diagnosis of fever or serious infection. EXPOSURE The ICD-9 diagnosis code groups were compared in 4 case-identification algorithms to a reference standard of fever ≥100.4°F documented in the medical record. MEASUREMENTS Algorithm predictive accuracy was measured using sensitivity, specificity, and negative and positive predictive values. RESULTS Among 1790 medical records reviewed, 766 (42.8%) infants had fever. Discharge diagnosis of fever demonstrated high specificity (98.2%, 95% confidence interval [CI]: 97.8-98.6) but low sensitivity (53.2%, 95% CI: 50.0-56.4). A case-identification algorithm of admission or discharge diagnosis of fever exhibited higher sensitivity (71.1%, 95% CI: 68.2-74.0), similar specificity (97.7%, 95% CI: 97.3-98.1), and the highest positive predictive value (86.9%, 95% CI: 84.5-89.3). CONCLUSIONS A case-identification strategy that includes admission or discharge diagnosis of fever should be considered for febrile infant studies using administrative data, though underclassification of patients is a potential limitation.

Alarm fatigue: Clearing the air

Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts; Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts.

The frequency of physiologic monitor alarms in a children's hospital

Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Division of Hospital Medicine, Lucile Packard Children’s Hospital Stanford, Palo Alto, California; Division of Critical Care, Children’s Hospital Los Angeles, Los Angeles, California; Department of Nursing, Johns Hopkins Hospital, Baltimore, Maryland; Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.

Association between Clinical Outcomes and Hospital Guidelines for Cerebrospinal Fluid Testing in Febrile Infants Aged 29-56 Days.

OBJECTIVE To describe the association between clinical outcomes and clinical practice guidelines (CPGs) recommending universal cerebrospinal fluid (CSF) testing in the emergency department for febrile infants aged 29-56 days. STUDY DESIGN Using 2007-2013 administrative data from 32 US childrens hospitals, we performed a difference-in-differences analysis comparing 7 hospitals with CPGs recommending universal CSF testing for older febrile infants aged 29-56 days (CPG group) with 25 hospitals without such CPGs (control group). We compared differences in clinical outcomes between older febrile infants with the corresponding differences among younger febrile infants aged 7-28 days. The primary outcome was the occurrence of an adverse event, defined as a delayed diagnosis of bacterial meningitis, mechanical ventilation, placement of a central venous catheter, extracorporeal membrane oxygenation, or in-hospital mortality. Analyses were adjusted for race/ethnicity, sex, median annual household income by zip code, primary insurance source, discharge season, and discharge year. RESULTS The proportion of older febrile infants undergoing CSF testing was higher (P < .001) in the CPG group (64.8%) than the control group (47.8%). CPGs recommending universal CSF testing for older febrile infants were not associated with significant differences in adverse events (difference-in-differences: +0.31 percentage points, 95% CI -0.18 to 0.85; P = .22). CONCLUSIONS Hospital CPGs recommending universal CSF testing for febrile infants aged 29-56 days were not associated with significant differences in clinical outcomes.

Caustic Ingestions Mimicking Anaphylaxis: Case Studies and Literature Review

Anaphylaxis presents in children with rapid involvement of typically 2 or more organ systems including cutaneous, gastrointestinal, and respiratory. Caustic ingestions (CI) may also present with acute involvement of cutaneous, gastrointestinal, and respiratory systems. We present 2 cases of “missed diagnosis” that illustrate how CI presenting with respiratory symptoms can be mistaken for anaphylaxis owing to these similarities. Both of these patients had delay in appropriate care for CI as a result. These cases demonstrate the importance of considering CI in children who have gastrointestinal symptoms, respiratory distress, and oropharyngeal edema.

Quality Improvement Feature Series Article 3: Writing and Reviewing Quality Improvement Manuscripts

Achieving rapid and meaningful improvement in healthcare requires the dissemination of quality improvement project results via publication. Doing this well requires detailed descriptions of the complex interventions and of the context in which the improvement took place. This report builds on the first 2 articles in the series to cover important considerations in writing quality improvement manuscripts with a focus on how it differs from writing traditional clinical research reports. The recommendations we outline here also apply to reviewing quality improvement manuscripts.

Physiologic Monitor Alarm Rates at 5 Children’s Hospitals

Alarm fatigue has been linked to patient morbidity and mortality in hospitals due to delayed or absent responses to monitor alarms. We sought to describe alarm rates at 5 freestanding children’s hospitals during a single day and the types of alarms and proportions of patients monitored by using a point-prevalence, cross-sectional study design. We collected audible alarms on all inpatient units and calculated overall alarm rates and rates by alarm type per monitored patient per day. We found a total of 147,213 alarms during the study period, with 3-fold variation in alarm rates across hospitals among similar unit types. Across hospitals, one-quarter of monitored beds were responsible for 71%, 61%, and 63% of alarms in medical-surgical, neonatal intensive care, and pediatric intensive care units, respectively. Future work focused on addressing nonactionable alarms in patients with the highest alarm counts may decrease alarm rates.