Marvin B. Harper

Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle

IMPORTANCE Handoff miscommunications are a leading cause of medical errors. Studies comprehensively assessing handoff improvement programs are lacking. OBJECTIVE To determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow. DESIGN, SETTING, AND PARTICIPANTS Prospective intervention study of 1255 patient admissions (642 before and 613 after the intervention) involving 84 resident physicians (42 before and 42 after the intervention) from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Childrens Hospital. INTERVENTIONS Resident handoff bundle, consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced. MAIN OUTCOMES AND MEASURES The primary outcomes were the rates of medical errors and preventable adverse events measured by daily systematic surveillance. The secondary outcomes were omissions in the printed handoff document and resident time-motion activity. RESULTS Medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3-40.3) to 18.3 per 100 admissions (95% CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95% CI, 1.7-4.8) to 1.5 (95% CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention (8.3%; 95% CI 7.1%-9.8%) vs 10.6% (95% CI, 9.2%-12.2%; P = .03). The average duration of verbal handoffs per patient did not change. Verbal handoffs were more likely to occur in a quiet location (33.3%; 95% CI, 14.5%-52.2% vs 67.9%; 95% CI, 50.6%-85.2%; P = .03) and private location (50.0%; 95% CI, 30%-70% vs 85.7%; 95% CI, 72.8%-98.7%; P = .007) after the intervention. CONCLUSIONS AND RELEVANCE Implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children. Improvements in verbal and written handoff processes occurred, and resident workflow did not change adversely.

Occult pneumonias : Empiric chest radiographs in febrile children with leukocytosis

STUDY OBJECTIVE We sought to determine the incidence of radiographic findings of pneumonia in highly febrile children with leukocytosis and no clinical evidence of pneumonia or other major infectious source. METHODS We conducted a prospective cohort study at a large urban pediatric hospital. Clinical practice guidelines for the use of chest radiography in febrile children were established by the emergency medicine attending staff. All records of emergency department patients with leukocytosis (WBC count >/= 20, 000/mm3), triage temperature 39.0 degreesC or higher, age 5 years or less were reviewed daily for 12 months. Physicians completed a questionnaire to note the diagnosis, the presence of respiratory symptoms and signs, and the reason for the chest radiograph (if one was obtained). Patients were excluded for immunodeficiency, chronic lung disease, or major bacterial sources of infection other than pneumonia. Pneumonia was defined by an attending radiologists reading of the radiograph. RESULTS We studied 278 patients. Chest radiographs were obtained in 225 for the following reasons: 79 because of respiratory findings suggestive of pneumonia and 146 because of leukocytosis and no identifiable major source of infection. Fifty-three patients did not undergo radiography. Pneumonia was found in 32 of 79 (40%; 95% confidence interval, 20% to 52%) of those with findings suggestive of pneumonia and in 38 of 146 (26%; 95% confidence interval, 19% to 34%) of those without clinical evidence of pneumonia. If patients who did not have a radiograph are assumed to not have pneumonia, the minimum estimate of occult pneumonia was 38 of 199 patients (19%; 95% confidence interval, 14% to 25%). CONCLUSION Empiric chest radiographs in highly febrile children with leukocytosis and no findings of pneumonia frequently reveal occult pneumonias. Chest radiography should be considered a routine diagnostic test in children with a temperature of 39 degreesC or greater and WBC count of 20,000/mm3 or greater without an alternative major source of infection.

Low risk of bacteremia in febrile children with recognizable viral syndromes.

BACKGROUND Previous studies of occult bacteremia in febrile children have excluded patients with recognizable viral syndromes (RVS). There is little information in the literature regarding the rate of bacteremia in febrile children with RVS. OBJECTIVE To determine the rate of bacteremia in children 3 to 36 months of age with fever and RVS. METHODS We performed a retrospective analysis of all patients 3 to 36 months of age with a temperature > or =39 degrees C seen during a 5 1/2-year period in the Emergency Department of a tertiary care pediatric hospital. From this group those with a discharge diagnosis of croup, varicella, bronchiolitis or stomatitis and no apparent concomitant bacterial infection were considered to have an RVS. The rate of bacteremia was determined for those subjects with RVS who had blood cultures. RESULTS Of 21,216 patients 3 to 36 months of age with a temperature > or =39 degrees C, 1347 (6%) were diagnosed with an RVS. Blood cultures were obtained in 876 (65%) of RVS patients. Of patients who had blood cultures, true pathogens were found in only 2 of 876 (0.2%) subjects with RVS [95% confidence interval (CI) 0.01, 0.8%]. The rate of bacteremia was 1 of 411 (0.2%) for subjects with bronchiolitis, O of 249 (0%) for subjects with croup, O of 123 (0%) for subjects with stomatitis and 1 of 93 (1.1%) for subjects with varicella. CONCLUSIONS Highly febrile children 3 to 36 months of age with uncomplicated croup, bronchiolitis, varicella or stomatitis have a very low rate of bacteremia and need not have blood drawn for culture.

Differentiating acute bacterial meningitis from acute viral meningitis among children with cerebrospinal fluid pleocytosis: a multivariable regression model.

Background: Although accurate models for predicting acute bacterial meningitis exist, most have narrow application because of the specific variables selected for them. In this study, we estimate the accuracy of a simple new model with potentially broader applicability. Methods: On the basis of previous reports, we created a reduced multivariable logistic regression model for predicting bacterial meningitis that relies on age (years) (AGE), cerebrospinal fluid (CSF), total protein (TP) and total neutrophil count (TNC) alone. Data were from children ages 1 month–18 years diagnosed with acute enteroviral or bacterial meningitis whose initial CSF revealed >7 white blood cells/mm3. A fractional polynomial model was specified and validated internally by the bootstrap procedure. The area under the receiver operating characteristic curve (discrimination: criterion standard, >0.7), the Hosmer-Lemeshow deciles-of-risk statistic (calibration: criterion standard, P > 0.05) and sensitivity-specificity pairs at prespecified probability thresholds of the model were computed. Results: We identified 60 children with bacterial meningitis and 82 with enteroviral meningitis. At an area under the receiver operating characteristic curve of 0.97, our model represented by the equation: log odds of bacterial meningitis = 0.343 − 0.003 TNC − 34.802 TP0.5 + 21.991 TP − 0.345 AGE, was highly accurate when differentiating between bacterial and enteroviral meningitis. The model fit the data well (Hosmer-Lemeshow statistic; P =[r] 0.53). At probability cutoffs between 0.1 and 0.4, the model had sensitivity values between 98 and 92% and specificity values between 62 and 94%. Conclusions: Among children with CSF pleocytosis, a prediction model based exclusively on age, CSF total protein and CSF neutrophils differentiates accurately between acute bacterial and viral meningitis.

A clinical practice guideline for treatment of septic arthritis in children: efficacy in improving process of care and effect on outcome of septic arthritis of the hip.

Background: The development of clinical practice guidelines is a central precept of the evidence-based-medicine movement. The purposes of this study were to develop a guideline for the treatment of septic arthritis in children and to evaluate its efficacy with regard to improving the process of care and its effect on the outcome of septic arthritis of the hip in children.Methods: A clinical practice guideline was developed by an interdisciplinary expert committee using evidence-based techniques. Efficacy was evaluated by comparing a historical control group of thirty consecutive children with septic arthritis of the hip managed before the utilization of the guideline with a prospective cohort group of thirty consecutive children treated with use of the guideline. Benchmark parameters of process and outcome were compared between groups.Results: The patients treated with use of the guideline, compared with those treated without use of the guideline, had a significantly higher rate of performance of initial and follow-up C-reactive protein tests (93% compared with 13% and 70% compared with 7%), lower rate of initial bone-scanning (13% compared with 40%), lower rate of presumptive drainage (13% compared with 47%), greater compliance with recommended antibiotic therapy (93% compared with 7%), faster change to oral antibiotics (3.9 compared with 6.9 days), and shorter hospital stay (4.8 compared with 8.3 days). There were no significant differences between the groups with regard to other process variables, and there were no significant differences with regard to outcome variables, including readmission to the hospital, recurrent infection, recurrent drainage, development of osteomyelitis, septic osteonecrosis, or limitation of motion.Conclusions: Patients treated according to the septic arthritis clinical practice guideline had less variation in the process of care and improved efficiency of care without a significant difference in outcome.Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

Utility of Lumbar Puncture for First Simple Febrile Seizure Among Children 6 to 18 Months of Age

OBJECTIVES. American Academy of Pediatrics consensus statement recommendations are to consider strongly for infants 6 to 12 months of age with a first simple febrile seizure and to consider for children 12 to 18 months of age with a first simple febrile seizure lumbar puncture for cerebrospinal fluid analysis. Our aims were to determine compliance with these recommendations and to assess the rate of bacterial meningitis detected among these children. METHODS. A retrospective cohort review was performed for patients 6 to 18 months of age who were evaluated for first simple febrile seizure in a pediatric emergency department between October 1995 and October 2006. RESULTS. First simple febrile seizure accounted for 1% of all emergency department visits for children of this age, with 704 cases among 71 234 eligible visits during the study period. Twenty-seven percent (n = 188) of first simple febrile seizure visits were for infants 6 to 12 months of age, and 73% (n = 516) were for infants 12 to 18 months of age. Lumbar puncture was performed for 38% of the children (n = 271). Samples were available for 70% of children 6 to 12 months of age (131 of 188 children) and 25% of children 12 to 18 months of age (129 of 516 children). Rates of lumbar puncture decreased significantly over time in both age groups. The cerebrospinal fluid white blood cell count was elevated in 10 cases (3.8%). No pathogen was identified in cerebrospinal fluid cultures. Ten cultures (3.8%) yielded a contaminant. No patient was diagnosed as having bacterial meningitis. CONCLUSIONS. The risk of bacterial meningitis presenting as first simple febrile seizure at ages 6 to 18 months is very low. Current American Academy of Pediatrics recommendations should be reconsidered.

Non-typhi Salmonella bacteremia in children.

BACKGROUND Non-typhi Salmonella (NTS) infections are a frequent cause of self-limited diarrheal illness in healthy children. Bacteremia is a known complication of NTS infection, but the management of children with bacteremia has been based on limited data. OBJECTIVE To study the outcomes of pediatric patients with NTS bacteremia. METHODS Retrospective review of patients with NTS bacteremia covering a 16-year period at an urban pediatric hospital. Clinical data from the initial visits and any follow-up visits or hospitalizations were abstracted from the medical record. RESULTS We studied 144 patients. Median age was 10.5 months. Fifty-four patients were hospitalized at the initial visit including all the patients with immunodeficiency (n = 12). Of the 90 patients initially managed as outpatients, 79 were subsequently admitted; only 1 of these patients developed a focal complication. Persistent bacteremia was found in 51 (41%) patients. Among nonimmunocompromised patients, persistent bacteremia was noted in 34% [95% confidence interval (CI), 20 to 52%] of those initially treated with oral antibiotics, 52% (CI 30 to 74%) of those initially treated with a parenteral dose of antibiotics and in 31% (CI 22 to 43%) of those who were not initially given antibiotics. No laboratory or clinical factors predicted persistent bacteremia. Twelve patients developed focal infections: 3 of 119 previously healthy children (2.5%, CI 0.5 to 7%); and 9 of 25 children with underlying medical conditions (36%, CI 19 to 57%). Focal infections included meningitis (3), osteomyelitis (4), septic arthritis (2), pneumonia (2) and cholangitis (1). CONCLUSIONS NTS bacteremia occurs in otherwise healthy children, although the risk of focal infections is small. Patients with NTS bacteremia frequently have persistent bacteremia at follow-up regardless of initial antibiotic treatment.

Predictors of Bacteremia in Febrile Children 3 to 36 Months of Age

Purpose. To develop an improved model for the prediction of bacteremia in young febrile children. Methods. A retrospective review was performed on patients 3 to 36 months of age seen in a childrens hospital emergency department between December 1995 and September 1997 who had a complete blood count and blood culture ordered as part of their regular care. Exclusion criteria included current use of antibiotics or any immunodeficient state. Clinical and laboratory parameters reviewed included age, gender, race, weight, temperature, presence of focal bacterial infection, white blood cell count (WBC), polymorphonuclear cell count (PMN), band count, and absolute neutrophil count (ANC). Logistic regression analyses were used to identify factors associated with bacteremia, defined as growth of a pathogen in a blood culture. The model that was developed was then validated on a second dataset consisting of febrile patients 3 to 36 months of age collected from a second childrens hospital (validation set). Results. There were 633 patients in the derivation set (46 bacteremic) and 9465 patients in the validation set (149 bacteremic). The mean age of patients in the derivation and validation sets were 15.8 months (95% confidence interval [CI]: 15.2–16.5) and 16.6 months (95% CI: 16.5–16.8), respectively; the mean temperatures were 39.1°C (95% CI: 39.0–39.2) and 39.8°C (95% CI: 39.7–39.8); 56% were male in the derivation set and 55% male in the validation set. Predictors of bacteremia identified by logistic regression included ANC, WBC, PMN, temperature, and gender. Receiver operator characteristic (ROC) analysis showed similar performance of ANC and WBC as predictors of bacteremia. When placed into a multivariate logistic regression model, band count was not significantly associated with bacteremia. Information regarding focal infection was available for 572 patients in the derivation set. The percentage of patients diagnosed with bacteremia with a focal bacterial infection was not significantly different from the percentage who had bacteremia without a focal bacterial infection (16/200 vs 30/372). Based on this dataset, a logistic regression formula was developed that could be used to develop a unique risk value for each patient based on temperature, gender, and ANC. When the final model was applied to the validation set, the area under the ROC curve (AUC) constructed from these data indicated that the model retained good predictive value (AUC for the derivation vs validation data = .8348 vs 0.8221, respectively). Conclusions. Use of the formulas derived here allows the clinician to estimate a childs risk for bacteremia based on temperature, ANC, and gender. This approach offers a useful alternative to predictions based on fever and WBC alone. bacteremia, detection, white blood cell.

Effect of antibiotic therapy on the outcome of outpatients with unsuspected bacteremia

The records of 559 consecutive outpatient children with unsuspected bacteremia (467 Streptococcus pneumoniae) were reviewed. When compared with patients receiving oral or parenteral antibiotics, those patients who received no antibiotics at the initial visit were in follow-up: (1) less likely to be improved (32% vs. 86%, P < 0.01); (2) more likely to be febrile (75% vs. 28%, P < 0.01); (3) more likely to be hospitalized (67% vs. 22%, P < 0.01); (4) more likely to have persistent bacteremia (28% vs. 3%, P < 0.01); and (5) more likely to have new focal infections (13% vs. 5%, P < 0.01). Compared with patients receiving parenteral antibiotics at the initial visit, patients receiving oral antibiotics were in follow-up: (1) less likely to be improved (81% vs. 89%, P < 0.05); and (2) more likely to have persistent bacteremia (5% vs. 0%, P < 0.05). There was no statistical difference between patients receiving parenteral or oral therapy in the development of focal infections, although children with new focal infections receiving oral antibiotics more often had persistent or new positive cultures. No patients receiving parenteral antibiotics at the initial visit had positive blood or spinal fluid cultures at the follow-up visit. Analyses of the subgroups with (1) occult bacteremia with all organisms, (2) unsuspected bacteremia S. pneumoniae and (3) occult bacteremia with S. pneumoniae show results similar to those for the entire group.(ABSTRACT TRUNCATED AT 250 WORDS)

Utility of sepsis evaluation in infants 90 days of age or younger with fever and clinical bronchiolitis.

Objective. To identify the clinical utility of obtaining blood, urine and cerebrospinal fluid for bacterial culture among febrile infants <90 days of age with clinical bronchiolitis. Design. Retrospective chart review from 1995 to 2000. Setting. Urban emergency department of a tertiary children’s hospital. Participants. All infants <90 days of age presenting with fever and clinical bronchiolitis. Main outcome measures. Result of the cultures of blood, urine and cerebrospinal fluid. Results. Of 3051 (11%) febrile infants, 329 met criteria for clinical bronchiolitis. Blood for culture was obtained from 309 (94%), urine for culture was obtained from 273 (83%) and cerebrospinal fluid for culture was obtained from 200 (61%). One hundred eighty-seven (57%) infants had all 3 specimens sent for culture. No cases of bacteremia [0%; 95% confidence interval (CI), 0, 1.1%] or meningitis (0%; 95% CI 0, 1.8%) occurred among these infants. However, 6 infants (2%; 95% CI 0.8, 5.7%), all male, had a culture of urine consistent with infection (4 Escherichia coli, 1 Staphylococcus aureus, 1 viridans streptococci). Conclusion. The risk of bacteremia or meningitis among infants <90 days with fever and bronchiolitis is low in this age group. The risk of urinary tract infection in this age group is also low, but not negligible, at 2%.