Karen E. Jerardi

Accuracy of Administrative Billing Codes to Detect Urinary Tract Infection Hospitalizations

BACKGROUND: Hospital billing data are frequently used for quality measures and research, but the accuracy of the use of discharge codes to identify urinary tract infections (UTIs) is unknown. OBJECTIVE: To determine the accuracy of International Classification of Diseases, 9th revision (ICD-9) discharge codes to identify children hospitalized with UTIs. METHODS: This multicenter study conducted in 5 childrens hospitals included children aged 3 days to 18 years who had been admitted to the hospital, undergone a urinalysis or urine culture, and discharged from the hospital. Data were obtained from the pediatric health information system database and medical record review. With the use of 2 gold-standard methods, the positive predictive value (PPV) was calculated for individual and combined UTI codes and for common UTI identification strategies. PPV was measured for all groupings for which the UTI code was the principal discharge diagnosis. RESULTS: There were 833 patients in the study. The PPV was 50.3% with the use of the gold standard of laboratory-confirmed UTIs but increased to 85% with provider confirmation. Restriction of the study cohort to patients with a principle diagnosis of UTI improved the PPV for laboratory-confirmed UTI (61.2%) and provider-confirmed UTI (93.2%), as well as the ability to benchmark performance. Other common identification strategies did not markedly affect the PPV. CONCLUSIONS: ICD-9 codes can be used to identify patients with UTIs but are most accurate when UTI is the principal discharge diagnosis. The identification strategies reported in this study can be used to improve the accuracy and applicability of benchmarking measures.

Blood Culture Time to Positivity in Febrile Infants With Bacteremia

IMPORTANCE Blood cultures are often obtained as part of the evaluation of infants with fever and these infants are typically observed until their cultures are determined to have no growth. However, the time to positivity of blood culture results in this population is not known. OBJECTIVE To determine the time to positivity of blood culture results in febrile infants admitted to a general inpatient unit. DESIGN, SETTING, AND PARTICIPANTS Multicenter, retrospective, cross-sectional evaluation of blood culture time to positivity. Data were collected by community and academic hospital systems associated with the Pediatric Research in Inpatient Settings Network. The study included febrile infants 90 days of age or younger with bacteremia and without surgical histories outside of an intensive care unit. EXPOSURES Blood culture growing pathogenic bacteria. MAIN OUTCOMES AND MEASURES Time to positivity and proportion of positive blood culture results that become positive more than 24 hours after placement in the analyzer. RESULTS A total of 392 pathogenic blood cultures were included from 17 hospital systems across the United States. The mean (SD) time to positivity was 15.41 (8.30) hours. By 24 hours, 91% (95% CI, 88-93) had turned positive. By 36 and 48 hours, 96% (95% CI, 95-98) and 99% (95% CI, 97-100) had become positive, respectively. CONCLUSIONS AND RELEVANCE Most pathogens in febrile, bacteremic infants 90 days of age or younger hospitalized on a general inpatient unit will be identified within 24 hours of collection. These data suggest that inpatient observation of febrile infants for more than 24 hours may be unnecessary in most infants.

Comparative Effectiveness of Empiric Antibiotics for Community-Acquired Pneumonia

BACKGROUND AND OBJECTIVE: Narrow-spectrum antibiotics are recommended as the first-line agent for children hospitalized with community-acquired pneumonia (CAP). There is little scientific evidence to support that this consensus-based recommendation is as effective as the more commonly used broad-spectrum antibiotics. The objective was to compare the effectiveness of empiric treatment with narrow-spectrum therapy versus broad-spectrum therapy for children hospitalized with uncomplicated CAP. METHODS: This multicenter retrospective cohort study using medical records included children aged 2 months to 18 years at 4 childrens hospitals in 2010 with a discharge diagnosis of CAP. Patients receiving either narrow-spectrum or broad-spectrum therapy in the first 2 days of hospitalization were eligible. Patients were matched by using propensity scores that determined each patient’s likelihood of receiving empiric narrow or broad coverage. A multivariate logistic regression analysis evaluated the relationship between antibiotic and hospital length of stay (LOS), 7-day readmission, standardized daily costs, duration of fever, and duration of supplemental oxygen. RESULTS: Among 492 patients, 52% were empirically treated with a narrow-spectrum agent and 48% with a broad-spectrum agent. In the adjusted analysis, the narrow-spectrum group had a 10-hour shorter LOS (P = .04). There was no significant difference in duration of oxygen, duration of fever, or readmission. When modeled for LOS, there was no difference in average daily standardized cost (P = .62) or average daily standardized pharmacy cost (P = .26). CONCLUSIONS: Compared with broad-spectrum agents, narrow-spectrum antibiotic coverage is associated with similar outcomes. Our findings support national consensus recommendations for the use of narrow-spectrum antibiotics in children hospitalized with CAP.

Bacteraemic urinary tract infection: Management and outcomes in young infants

Objectives To determine predictors of parenteral antibiotic duration and the association between parenteral treatment duration and relapses in infants <3 months with bacteraemic urinary tract infection (UTI). Design Multicentre retrospective cohort study. Setting Eleven healthcare institutions across the USA. Patients Infants <3 months of age with bacteraemic UTI, defined as the same pathogenic organism isolated from blood and urine. Main outcome measures Duration of parenteral antibiotic therapy, relapsed UTI within 30 days. Results The mean (±SD) duration of parenteral antibiotics for the 251 included infants was 7.8 days (±4 days), with considerable variability between institutions (mean range 5.5–12 days). Independent predictors of the duration of parenteral antibiotic therapy included (coefficient, 95% CI): age (−0.2 days, −0.3 days to −0.08 days, for each week older), year treated (−0.2 days, −0.4 to −0.03 days for each subsequent calendar year), male gender (0.9 days, 0.01 to 1.8 days), a positive repeat blood culture during acute treatment (3.5 days, 1.2–5.9 days) and a non-Escherichia coli organism (2.2 days, 0.8–3.6 days). No infants had a relapsed bacteraemic UTI. Six infants (2.4%) had a relapsed UTI (without bacteraemia). The duration of parenteral antibiotics did not differ between infants with and without a relapse (8.2 vs 7.8 days, p=0.81). Conclusions Parenteral antibiotic treatment duration in young infants with bacteraemic UTI was variable and only minimally explained by measurable patient factors. Relapses were rare and were not associated with treatment duration. Shorter parenteral courses may be appropriate in some infants.

Investment in Faculty as Educational Scholars: Outcomes from the National Educational Scholars Program

From the Department of Pediatrics, Cincinnati Children’s Hospital Medical Center/ University of Cincinnati College of Medicine, Cincinnati, OH; Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX; Department of Pediatrics, Stony Brook University School of Medicine, Stony Brook, NY; and Department of Pediatrics, University of Rochester Medical Center, A cademic institutions have strong incentives to develop faculty who are productive researchers, master clinicians, and educators. Forward-thinking institutions are encouraging their educators to become not only stellar teachers, but also productive scholars through peerreviewed dissemination of rigorously developed and evaluated curricular innovations, evaluation tools, and teaching methodologies. This emphasis on evaluation is imperative to ensure that educational programs effectively and efficiently meet the needs of the learners and the healthcare system. Even though many educator development programs train faculty to be good teachers, relatively few emphasize educational scholarship and research. Moreover, few of these are national programs offering participants the benefits of national mentoring and networking. The Educational Scholars Program (ESP) is a competitive national faculty development program created by the Academic Pediatric Association in 2006. The ESP is designed to cultivate skills in developing and evaluating curricula, conducting methodologically sound educational research, and effectively disseminating scholarly work. Mentorship and networking are key components of the ESP; each scholar is paired with a local project mentor and a national advisor with proven educational scholarship skills. Cohorts of scholars complete a 3-year longitudinal curriculum, including day-long sessions at 3 Pediatric Academic Society meetings and 6 online learning modules, each focused on specific educational scholarship skills. The cohorts form learning communities and serve as peer mentors. Scholars create an educator portfolio documenting their teaching activities and scholarly accomplishments. They also complete an educational project that they disseminate via peerreviewed publication or national presentation. The goal of this study was to describe the professional impact and value of the ESP on graduates and their institutions.

Assessment of readability, understandability, and completeness of pediatric hospital medicine discharge instructions.

&NA; The average American adult reads at an 8th‐grade level. Discharge instructions written above this level might increase the risk of adverse outcomes for children as they transition from hospital to home. We conducted a cross‐sectional study at a large urban academic childrens hospital to describe readability levels, understandability scores, and completeness of written instructions given to families at hospital discharge. Two hundred charts for patients discharged from the hospital medicine service were randomly selected for review. Written discharge instructions were extracted and scored for readability (Fry Readability Scale [FRS]), understandability (Patient Education Materials Assessment Tool [PEMAT]), and completeness (5 criteria determined by consensus). Descriptive statistics enumerated the distribution of readability, understandability, and completeness of written discharge instructions. Of the patients included in the study, 51% were publicly insured. Median age was 3.1 years, and median length of stay was 2.0 days. The median readability score corresponded to a 10th‐grade reading level (interquartile range, 8‐12; range, 1‐13). Median PEMAT score was 73% (interquartile range, 64%‐82%; range, 45%‐100%); 36% of instructions scored below 70%, correlating with suboptimal understandability. The diagnosis was described in only 33% of the instructions. Although explicit warning signs were listed in most instructions, 38% of the instructions did not include information on the person to contact if warning signs developed. Overall, the readability, understandability, and completeness of discharge instructions were subpar. Efforts to improve the content of discharge instructions may promote safe and effective transitions home.

Admission chest radiographs predict illness severity for children hospitalized with pneumonia

OBJECTIVE To assess whether radiographic findings predict outcomes among children hospitalized with pneumonia. METHODS This retrospective study included children <18 years of age from 4 childrens hospitals admitted in 2010 with clinical and radiographic evidence of pneumonia. Admission radiographs were categorized as single lobar, unilateral or bilateral multilobar, or interstitial. Pleural effusions were classified as absent, small, or moderate/large. Propensity scoring was used to adjust for potential confounders, including need for supplemental oxygen, intensive care, and mechanical ventilation, as well as hospital length of stay and duration of supplemental oxygen. RESULTS There were 406 children (median age, 3 years). Infiltrate patterns included: single lobar, 61%; multilobar unilateral, 13%; multilobar bilateral, 16%; and interstitial, 10%. Pleural effusion was present in 21%. Overall, 63% required supplemental oxygen (median duration, 31.5 hours), 8% required intensive care, and 3% required mechanical ventilation. Median length of stay was 51.5 hours. Compared with single lobar infiltrate, all other infiltrate patterns were associated with need for intensive care; only bilateral multilobar infiltrate was associated with need for mechanical ventilation (adjusted odds ratio [aOR]: 3.0, 95% confidence interval [CI]: 1.2-7.9). Presence of effusion was associated with increased length of stay and duration of supplemental oxygen; only moderate/large effusion was associated with need for intensive care (aOR: 3.2, 95% CI: 1.1-8.9) and mechanical ventilation (aOR: 14.8, 95% CI: 9.8-22.4). CONCLUSIONS Admission radiographic findings are associated with important hospital outcomes and care processes and may help predict disease severity.

Discordant antibiotic therapy and length of stay in children hospitalized for urinary tract infection

BACKGROUND Urinary tract infections (UTIs) are a common reason for pediatric hospitalizations. OBJECTIVE To determine the effect of discordant antibiotic therapy (in vitro nonsusceptibility of the uropathogen to initial antibiotic) on clinical outcomes for children hospitalized for UTI. DESIGN/SETTING Multicenter retrospective cohort study in children aged 3 days to 18 years, hospitalized at 5 childrens hospitals with a laboratory-confirmed UTI. Data were obtained from medical records and the Pediatric Hospital Information System (PHIS) database. PARTICIPANTS Patients with laboratory-confirmed UTI. MAIN EXPOSURE Discordant antibiotic therapy. MEASUREMENTS Length of stay and fever duration. Covariates included age, sex, insurance, race, vesicoureteral reflux, antibiotic prophylaxis, genitourinary abnormality, and chronic care conditions. RESULTS The median age of the 216 patients was 2.46 years (interquartile range [IQR]: 0.27, 8.89) and 25% were male. The most common causative organisms were E. coli and Klebsiella species. Discordant therapy occurred in 10% of cases and most commonly in cultures positive for Klebsiella species, Enterobacter species, and mixed organisms. In adjusted analyses, discordant therapy was associated with a 1.8 day (95% confidence interval [CI]: 1.5, 2.1) longer length of stay [LOS], but not with fever duration. CONCLUSIONS Discordant antibiotic therapy for UTI is common and associated with longer hospitalizations. Further research is needed to understand the clinical factors contributing to the increased LOS and to inform decisions for empiric antibiotic selection in children with UTIs.

Improving the readability of pediatric hospital medicine discharge instructions

BACKGROUND: Readable discharge instructions may help caregivers understand and implement care plans following hospitalization. Many caregivers of hospitalized children, however, have limited literacy. We aimed to increase the percentage of discharge instructions written at 7th grade level or lower for hospital medicine patients from 13% to 80% in 6 months. METHODS: Quality improvement efforts targeted a 42‐bed unit at the community satellite of our large, urban academic hospital. A multidisciplinary team of physicians, nurses, and parents focused on key drivers: family engagement in discharge process, standardization of discharge instructions, staff engagement in discharge preparedness, and audit and feedback of data. Improvement cycles included 1) education and implementation of a general discharge instruction template in the electronic health record (EHR); 2) visible reminders and tips for writing readable discharge instructions; 3) implementation of disease‐specific discharge instruction templates in the EHR; and 4) individualized feedback to staff on readability and content of their written discharge instructions. Instructions were individually scored for readability using an online platform. An annotated control chart assessed the impact of interventions over time. RESULTS: Through sequential interventions over 6 months, the percentage of discharge instructions written at 7th grade or lower readability level increased from 13% to 98% and has been sustained for 4 months. The reliable use of the EHR templates was associated with our largest improvements. CONCLUSION: Use of standardized discharge instruction templates and rapid feedback to staff improved the readability of instructions. Next steps include adaptation and spread to other patient populations.

Development of a Curricular Framework for Pediatric Hospital Medicine Fellowships

PHM fellowship directors have developed a standardized curricular framework for 2-year fellowship in PHM. Pediatric Hospital Medicine (PHM) is an emerging field in pediatrics and one that has experienced immense growth and maturation in a short period of time. Evolution and rapid expansion of the field invigorated the goal of standardizing PHM fellowship curricula, which naturally aligned with the field’s evolving pursuit of a defined identity and consideration of certification options. The national group of PHM fellowship program directors sought to establish curricular standards that would more accurately reflect the competencies needed to practice pediatric hospital medicine and meet future board certification needs. In this manuscript, we describe the method by which we reached consensus on a 2-year curricular framework for PHM fellowship programs, detail the current model for this framework, and provide examples of how this curricular framework may be applied to meet the needs of a variety of fellows and fellowship programs. The 2-year PHM fellowship curricular framework was developed over a number of years through an iterative process and with the input of PHM fellowship program directors (PDs), PHM fellowship graduates, PHM leaders, pediatric hospitalists practicing in a variety of clinical settings, and other educators outside the field. We have developed a curricular framework for PHM Fellowships that consists of 8 education units (defined as 4 weeks each) in 3 areas: clinical care, systems and scholarship, and individualized curriculum.