Daniel J. Sklansky

Preventing Hospitalizations in Children With Medical Complexity: A Systematic Review

BACKGROUND AND OBJECTIVES: Children with medical complexity (CMC) account for disproportionately high hospital use, and it is unknown if hospitalizations may be prevented. Our objective was to summarize evidence from (1) studies characterizing potentially preventable hospitalizations in CMC and (2) interventions aiming to reduce such hospitalizations. METHODS: Our data sources include Medline, Cochrane Central Register of Controlled Trials, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases from their originations, and hand search of article bibliographies. Observational studies (n = 13) characterized potentially preventable hospitalizations, and experimental studies (n = 4) evaluated the efficacy of interventions to reduce them. Data were extracted on patient and family characteristics, medical complexity and preventable hospitalization indicators, hospitalization rates, costs, and days. Results of interventions were summarized by their effect on changes in hospital use. RESULTS: Preventable hospitalizations were measured in 3 ways: ambulatory care sensitive conditions, readmissions, or investigator-defined criteria. Postsurgical patients, those with neurologic disorders, and those with medical devices had higher preventable hospitalization rates, as did those with public insurance and nonwhite race/ethnicity. Passive smoke exposure, nonadherence to medications, and lack of follow-up after discharge were additional risks. Hospitalizations for ambulatory care sensitive conditions were less common in more complex patients. Patients receiving home visits, care coordination, chronic care-management, and continuity across settings had fewer preventable hospitalizations. Conclusions: There were a limited number of published studies. Measures for CMC and preventable hospitalizations were heterogeneous. Risk of bias was moderate due primarily to limited controlled experimental designs. Reductions in hospital use among CMC might be possible. Strategies should target primary drivers of preventable hospitalizations.

Comparison of Isotonic and Hypotonic Intravenous Maintenance Fluids: A Randomized Clinical Trial

IMPORTANCE Use of hypotonic intravenous fluids for maintenance requirements is associated with increased risk of hyponatremia that results in morbidity and mortality in children. Clinical trial data comparing isotonic and hypotonic maintenance fluids in nonsurgical hospitalized pediatric patients outside intensive care units are lacking. OBJECTIVE To compare isotonic (sodium chloride, 0.9%, and dextrose, 5%) with hypotonic (sodium chloride, 0.45%, and dextrose, 5%) intravenous maintenance fluids in a hospitalized general pediatric population. DESIGN, SETTING, AND PARTICIPANTS In this double-blind randomized clinical trial,we recruited 110 children admitted to a general pediatric unit of a tertiary care childrens hospital from March 1, 2008, through August 31, 2012 (age range, 1 month to 18 years), with normal baseline serum sodium levels who were anticipated to require intravenous maintenance fluids for 48 hours or longer (intent-to-treat analyses). Children with diagnoses that required specific fluid tonicity and volumes were excluded. INTERVENTIONS Patients were randomized to receive isotonic or hypotonic intravenous fluid at maintenance rates for 48 hours. MAIN OUTCOMES AND MEASURES The primary outcome was mean serum sodium level at 48 hours. The secondary outcomes were mean sodium level at 24 hours, hyponatremia and hypernatremia, weight gain, hypertension, and edema. Confounding variables were included in multiple regression models. Post hoc analyses included change from baseline sodium level at 24 and 48 hours and subgroup analysis of children with primary respiratory diagnosis. RESULTS Of 110 enrolled patients, 54 received isotonic fluids and 56 received hypotonic fluids. The mean (SD) sodium level at 48 hours was 139.9 (2.7) mEq/L in the isotonic group and 139.6 (2.6) mEq/L in the hypotonic group (95% CI of the difference, -0.94 to 1.74 mEq/L; P = .60). Two patients in the hypotonic group developed hyponatremia, 1 in each group developed hypernatremia, 2 in each group developed hypertension, and 2 in the isotonic group developed edema. Mean (SD) change from baseline to 48-hour sodium level was +1.3 (2.9) vs -0.12 (2.8) mEq/L, respectively (absolute difference, 1.4 mEq/L; 95% CI of the difference, -0.01 to 2.8 mEq/L; P = .05). CONCLUSIONS AND RELEVANCE Our study results support the notion that isotonic maintenance fluid administration is safe in general pediatric patients and may result in fewer cases of hyponatremia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00632775.

Hyponatremia-Associated Rhabdomyolysis Following Exercise in an Adolescent With Cystic Fibrosis

Adolescents with well-controlled cystic fibrosis, including good lung function and appropriate growth, commonly participate in competitive athletic activities. We present the case of an adolescent male with cystic fibrosis, hyponatremia, dehydration, and rhabdomyolysis after participating in football practice on a summer morning. The patient presented with severe myalgia and serum sodium of 129 mmol/L, chloride 90 mmol/L, and creatine phosphokinase 1146 U/L. Aggressive hydration with intravenous 0.9% saline resulted in clinical improvement with no renal or muscular sequelae. Health care providers need to educate patients with cystic fibrosis about maintaining adequate hydration and sodium repletion during exercise. Research is needed regarding the appropriate amount and composition of oral rehydration fluids in exercising individuals with cystic fibrosis, as the physiology encountered in these patients provides a unique challenge to maintaining electrolyte balance and stimulation of thirst.

Trends in Hospital Treatment of Empyema in Children in the United States

Objective To evaluate trends in procedures used to treat children hospitalized in the US with empyema during a period that included the release of guidelines endorsing chest tube placement as an acceptable first‐line alternative to video‐assisted thoracoscopic surgery. Study design We used National Inpatient Samples to describe empyema‐related discharges of children ages 0‐17 years during 2008‐2014. We evaluated trends using inverse variance weighted linear regression and characterized treatment failure using multivariable logistic regression to identify factors associated with having more than 1 procedure. Results Empyema‐related discharges declined from 3 in 100 000 children to 2 in 100 000 during 2008‐2014 (P = .04, linear trend). There was no significant change in the proportion of discharges having 1 procedure (66.1% to 64.1%) or in the proportion having 2 or more procedures (22.1% to 21.6%). The proportion coded for video‐assisted thoracoscopic surgery as the only procedure declined (41.4% to 36.2%; P = .03), and the proportions coded for 1 chest tube (14.6% to 20.9%; P = .04) and 2 chest tube procedures (0.9% to 3.5%; P < .01) both increased. The median length of stay for empyema‐related discharges remained unchanged (9.3 days to 9.8 days; P = .053). Having more than 1 procedure was associated with continuous mechanical ventilation (adjusted OR, 2.7; 95% CI, 1.8‐4.1) but not with age, sex, payer, chronic conditions, transfer admission, hospital size, or census region. Conclusions The use of video‐assisted thoracoscopic surgery to treat children in the US hospitalized with empyema seems to be decreasing without associated increases in length of stay or need for additional drainage procedures.

Thresholds and interpretations: How clinical competency committees identify pediatric residents with performance concerns

Abstract Background: Clinical competency committee (CCC) identification of residents with performance concerns is critical for early intervention. Methods: Program directors and 94 CCC members at 14 pediatric residency programs responded to a written survey prompt asking them to describe how they identify residents with performance concerns. Data was analyzed using thematic analysis. Results: Six themes emerged from analysis and were grouped into two domains. The first domain included four themes, each describing a path through which residents could meet or exceed a concern threshold:1) written comments from rotation assessments are foundational in identifying residents with performance concerns, 2) concerning performance extremes stand out, 3) isolated data points may accumulate to raise concern, and 4) developmental trajectory matters. The second domain focused on how CCC members and program directors interpret data to make decisions about residents with concerns and contained 2 themes: 1) using norm- and/or criterion-referenced interpretation, and 2) assessing the quality of the data that is reviewed. Conclusions: Identifying residents with performance concerns is important for their education and the care they provide. This study delineates strategies used by CCC members across several programs for identifying these residents, which may be helpful for other CCCs to consider in their efforts.

Are You Going Overboard on Cephalosporins

#### The study This prospective chart review study (2011–2013) from Texas included infants aged ≤60 days with a positive culture from the blood, urine, or cerebrospinal fluid. The researcher’s objectives were to study the pathogens and the optimal choice of antibiotics in infants with serious bacterial infection (SBI). #### The key findings The study found 265 infants with SBI. Of those infants, 11% had meningitis, 25% had bacteremia or bacteremia with urinary tract infection, and 64% had urinary tract infection alone. Escherichia coli and group B Streptococcus were the predominate pathogens. There were no cases of methicillin-resistant Staphylococcus aureus , vancomycin-resistant Enterococcus , or penicillin-resistant Streptococcus pneumonia. For infants aged ≤28 days, the combination of ampicillin and gentamicin was used in 78% of cases, whereas a third-generation cephalosporin was used in 22% of cases. For infants aged ≥29 days, ampicillin and gentamicin were used in 13% of cases, and a third-generation cephalosporin was used in 87% of cases. The authors noted that when meningitis was not suspected, regimens of either ampicillin/gentamicin or a third-generation cephalosporin were equally effective based on susceptibility data (96% and 97%). They also noted that 67% of cases in which a third-generation cephalosporin was used resulted in unnecessarily broad coverage compared with ampicillin/gentamicin. Also, …

Preventing Bounce-Backs: More Filled Meds, Less Hurting Heads.

We all want to reduce readmissions. Children hospitalized with asthma account for a significant proportion of hospitalizations and, thus, readmissions. Do our patients take their medications as often as we think? Do they even fill the prescriptions? By increasing prescription fill rate, can we reduce hospital readmissions? #### The study This retrospective cohort analysis of Medicaid claims data included >30 000 children from 12 states who were hospitalized for asthma from 2005 to 2007. The study linked hospitalization for asthma and readmission for asthma with β-agonist medication fill rate, oral steroid fill rate, and inhaled steroid fill rate. Readmission was defined as hospitalization with a primary or secondary diagnosis of asthma within 90 days of discharge. Prescription filling included pharmacy claims 1 day before discharge to 3 days after discharge. The authors hypothesized that filling of β-agonists and oral steroids would be associated with reduction in short-term readmission (≤14 days) and that filling inhaled steroids would reduce readmission at later intervals. #### The key findings Of the >30 000 children hospitalized for asthma, 55% filled a prescribed β-agonist, 57% filled an oral steroid, and 37% filed an inhaled steroid. Readmission occurred for 1.3% of children by 14 days and 6.3% by 90 days. After adjusting for patient and billing factors, filled prescriptions for β-agonists (hazard ratio 0.67, 95% confidence ration …

More Bark, Less Bite

Pets, particularly dogs, are often seen on the pediatric ward for playtime with patients. Does evidence suggest that they have a positive effect on measurable outcomes? ### The study. This randomized controlled trial sought to determine if canine animal-assisted therapy improved pain scores and patient satisfaction in adults undergoing elective knee and hip arthroplasties. Patients assigned to the treatment group were visited daily for 3 days by a certified pet therapy dog for 15 minutes before physical therapy sessions. Outcomes were determined by using a validated visual analog scale (VAS) for pain and the Hospital Consumer Assessment of Healthcare Providers and Systems survey from the Centers for Medicare and Medicaid Services to measure patient satisfaction. ### The key findings. A total of 72 patients were randomized to treatment and control groups, with 36 in each group. Those undergoing animal-assisted therapy had lower VAS scores. After the first session, the treatment group (VAS 5.2, SD 1.4, 95% confidence interval [CI] 4.71–5.64) had an average VAS pain score 2.0 U lower than that of the control group (VAS 7.2, SD 1.4, 95% CI 6.71–7.3, P < .001). The final VAS score difference at day 3 was 2.4 U ( P < .001). Compared with the control group, the treatment group …

Call me? Maybe, stick me? Maybe not!

Discharge telephone calls have been suggested as a method to increase patient satisfaction, therapy compliance, and follow-up while decreasing readmission rates and cost. Is there evidence to support this practice? ### The study. This retrospective observational analysis asked the question, “How does a postdischarge telephone call affect 30-day readmission in a general adult medicine population?” Patients were called within 72 hours after discharge by a nurse with the purpose of solving issues related to discharge (eg, medications, follow-up care). ### The key findings. Patients who were called and reached had a 5.8% readmission rate. Patients who were called but not reached or who did not complete the telephone call had a readmission rate of 8.6%. Other patients for whom there was no attempt to complete a call were readmitted at a rate of 8.3%. It would seem that a simple telephone call decreased readmission rates by ∼29% (adjusted odds ratio [aOR]: 0.71 [95% confidence interval (CI): 0.55–0.91]). However, when the data were adjusted to account for demographic characteristics that might have introduced bias in selection of patients included, no association between receiving a call and readmission rate was observed for the population as a …