Patricia S. Lye

Reliability of observation variables in distinguishing infectious outcome of febrile young infants.

We prospectively evaluated 7 observation variables (level of activity, level of alertness, respiratory status/effort, peripheral perfusion, muscle tone, affect, feeding pattern) which qualify patient clinical appearance in order to determine reliability in distinguishing the infectious outcome of 233 febrile infants ages 0 to 8 weeks. Each variable was graded either 1, 3, or 5, with a higher score indicative of a greater degree of compromise. All infants received physical examination and sepsis evaluation (lumbar puncture, complete blood count/blood culture, urinalysis/urine culture). The 3 outcome groups compared were 29 cases of serious bacterial infections, (+SBI; 10 with bacterial meningitis, 12 with bacteremia, 7 with urinary tract infection), 45 cases of aseptic meningitis (AM) and 159 cases culture-negative with normal cerebrospinal fluid (CN-NCSF). The mean score for each of the 7 variables was significantly greater in the +SBI group compared with both the AM and CN-NCSF groups (P < 0.05), whereas there was no significant difference in mean score for each of the 7 variables between the AM and CN-NCSF groups. Stepwise discriminant analysis identified 3 variables that best distinguished outcome: affect; respiratory status/effort; and peripheral perfusion, which constituted the Young Infant Observation Scale. The mean total Young Infant Observation Scale score generated from assessing these 3 variables was significantly greater (P = 0.0001) in the +SBI, group (9) compared with both the AM (5) and CN-NCSF (5) groups. A total Young Infant Observation Scale score > or = 7 had a sensitivity of 76%, specificity of 75% and negative-predictive value of 96% for outcome of +SBI.

Policy statement - Principles of pediatric patient safety: Reducing harm due to medical care

Pediatricians are rendering care in an environment that is increasingly complex, which results in multiple opportunities to cause unintended harm. National awareness of patient safety risks has grown in the 10 years since the Institute of Medicine published its report To Err Is Human, and patients and society as a whole continue to challenge health care providers to examine their practices and implement safety solutions. The depth and breadth of harm incurred by the practice of medicine is still being defined as reports continue to uncover a variety of avoidable errors, from those that involve specific high-risk medications to those that are more generalizable, such as patient misidentification. Pediatricians in all venues must have a working knowledge of patient-safety language, advocate for best practices that attend to risks that are unique to children, identify and support a culture of safety, and lead efforts to eliminate avoidable harm in any setting in which medical care is rendered to children.

Clinical Report—Physicians' Roles in Coordinating Care of Hospitalized Children

The care of hospitalized children and adolescents has become increasingly complex and often involves multiple physicians beyond the traditional primary care pediatrician. Hospitalists, medical subspecialists, surgical specialists, and hospital attending physicians may all participate in the care of hospitalized children and youth. This report summarizes the responsibilities of the pediatrician and other involved physicians in ensuring that children receive coordinated and comprehensive medical care delivered within the context of their medical homes as inpatients, and that care is appropriately continued on an outpatient basis.

Pediatric Hospitalists: Report of a Leadership Conference

OBJECTIVES. To summarize a meeting of academic pediatric hospitalists and to describe the current state of the field. METHODS. The Ambulatory Pediatric Association sponsored a meeting for academic pediatric hospitalists in November 2003. The purpose of the meeting was to discuss and to define roles of academic pediatric hospitalists, including their roles as clinicians, educators, and researchers, and to discuss organizational issues and unique hospitalist issues within general academic pediatrics. Workshops were held in the areas of organization and administration, academic life, research, and education. A literature review was also conducted in the areas discussed. RESULTS. More than 130 physicians attended. Thirteen workshops were held, and all information was summarized in large-group sessions for all attendees. CONCLUSIONS. Pediatric hospital medicine is a rapidly growing field, with an estimated 800 to 1000 pediatric hospitalists currently practicing. Initial work has defined the clinical environment and has begun to stake out a unique knowledge and skill set. The Pediatric Hospitalists in Academic Settings conference demonstrated the audience for additional development and the resources to move forward.

Clinical impact of radiograph misinterpretation in a pediatric ED and the effect of physician training level

Radiograph interpretation in the pediatric emergency department (ED) is commonly performed by pediatric emergency medicine (PEM) attendings or physicians-in-training. This study examines the effect of physician training level on radiograph interpretation and the clinical impact of false-negative radiograph interpretations. Data were collected on 1,471 radiographs of the chest, abdomen, extremity, lateral neck, and cervical spine interpreted by PEM attendings, one PEM fellow, one physician assistant, and emergency medicine, pediatric and family practice residents. Two hundred radiographs (14%) were misinterpreted, including 141 chest (16%), 24 extremity (8%), 20 abdomen (12%), 14 lateral neck (18%), and 1 cervical spine radiograph (2%). Physicians-in-training misinterpreted 16% of their radiographs versus 11% for PEM attendings (P = .01). Twenty (1.4%) radiographs had clinically significant (false-negative) misinterpretations, including 1.7% of physician-in-training and 0.8% of attending interpretations (P = 0.15). No morbidity resulted from the delay in correct interpretation. Radiograph misinterpretation by ED physicians occurs but is unlikely to result in significant morbidity.

Factors predicting prolonged hospital stay for infants with bronchiolitis.

BACKGROUND Prior prediction models for length of stay (LOS) in bronchiolitis have focused more on birth- and disease-related risk factors than on early hospital course factors, particularly common clinical markers including respiratory status and caloric intake. OBJECTIVES 1) Study the associations of various clinical markers and LOS; and 2) develop a LOS prediction model. DESIGN Retrospective cohort study. SETTING Childrens Hospital of Wisconsin. PATIENTS Inclusion criteria were: age < 365 days old; admission between November 1, 2004 and April 15, 2005; final diagnosis of bronchiolitis; placement on the bronchiolitis treatment protocol; and lack of concurrent condition impacting LOS. RESULTS During the study period, 272/347 infants admitted with bronchiolitis met inclusion criteria. On hospital day 2, infants in the prolonged LOS group (≥ 108 hours) had a significantly greater number of hours on supplemental oxygen, maximum supplemental oxygen use, minimum supplemental oxygen use, maximum respiratory rate, mean respiratory score, and number of times suctioned. They had significantly lower minimum oxygen saturation and caloric intake. Recursive partitioning demonstrated five variables (hours of supplemental oxygen, maximum respiratory rate, minimum supplemental oxygen use, gestation, and caloric intake) to predict short or prolonged LOS with an area under the receiver-operator characteristic curve of 0.89/0.72 in the learning/test trees; sensitivity, 0.85; and specificity, 0.82. CONCLUSIONS There are important differences between infants with bronchiolitis having short and prolonged hospital stays, including several clinical markers identifiable on hospital day 2. This model may be a useful prediction tool for targeting early interventions for high-risk infants.

Advised follow-up after emergency treatment of adolescents with violence-related injuries.

Objective: To compare the rate of advised medical follow‐up for adolescents with violence‐related, nonsuicidal injuries versus other complaints. Design: Cross‐sectional study. Setting: Pediatric emergency department (ED). Patients: All visits by adolescents, aged 13 to 18 years, during a one‐week period from each season during 1992. Main outcome measures/results: Advised medical follow‐up for patients sustaining violence‐related injuries versus other complaints were compared. Four hundred twenty‐six visits were reviewed; 351(82%) resulted in discharge from the ED. Sixty‐eight (16%) were classified as violence‐related, nonsuicidal. Male adolescents were more likely to sustain violence‐related injuries (66% vs 34%, P < 0.01). There were no differences in admission rate or having a primary care provider (PCP) between the violence‐related injury group and the group with other complaints. Adolescents with other complaints were twice as likely to have follow‐up advised. Presence of PCP and older age were also positively associated with advised follow‐up. Conclusion: Adolescents sustaining violence‐related injuries were less likely to have follow‐up advised at the time of their ED visit than were adolescents presenting with other complaints. Violently injured adolescents, at risk for recurrent violent injuries and psychosocial sequelae, were less likely to have follow‐up advised at the time of their ED visit than were adolescents presenting with other complaints.

Pediatric observation units.

Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.

Adolescent health care in a pediatric emergency department

STUDY OBJECTIVE We examined the use of the pediatric emergency department of an urban childrens hospital by adolescents. This study included visits by all adolescents aged 13 to 18 years in a 1-week period from each season during 1992. RESULTS The ED saw 426 adolescents, representing approximately 15% of the total ED visits. Fifty percent of these patients were male. More than half of the patients were black; a few were members of other minority groups. Eighteen percent had emergency, 60% urgent, and 21% nonurgent conditions. Forty-three percent of the patients came to the ED between 3 PM and 11 PM. Injuries accounted for 47% of male visits and 42% of female visits. Approximately half of the injuries resulted from violent events. Twenty-seven percent of the visits were for exacerbation of a chronic illness such as asthma or diabetes. The most common reason for adolescent female visits was gynecologic problems. Injury was the most common reason for adolescent male visits. Only 27% of the adolescents lived in a two-parent home. In 16% of the cases, the adolescents were treated without consent. Nineteen percent of the adolescents were uninsured, and nearly 50% were publicly insured. CONCLUSION Issues of violence, consent, and insurance present problems for many adolescents in the pediatric ED. Injuries, particularly those related to violent events, are cause for many adolescent visits. ED staff members should develop plans to care for the complex psychosocial and medical problems of adolescents.

Relationship of temperature pattern and serious bacterial infections in infants 4 to 8 weeks old 24 to 48 hours after antibiotic treatment

STUDY OBJECTIVE A new management approach to selected febrile infants 4 to 8 weeks old evaluated for possible sepsis is outpatient ceftriaxone therapy, with subsequent re-evaluation 24 to 48 hours after presentation. This study assessed whether the temperature profile of such infants during the 24- to 48-hour period after treatment distinguished those with from those without serious bacterial infections (SBIs). DESIGN Prospective, descriptive clinical study. PARTICIPANTS One hundred sixty-one febrile infants 4 to 8 weeks old. SETTING An urban pediatric emergency department and hospital. MEASUREMENTS AND MAIN RESULTS All infants underwent a sepsis evaluation (lumbar puncture, CBC/blood culture, and urinalysis/urine culture) and were hospitalized for at least 48 hours. Temperatures were measured on presentation and then every four hours during hospitalization. All infants received parenteral third-generation cephalosporin antibiotic therapy, and none received antipyretic medication unless fever was documented. Fever (rectal temperature of more than 38.0 C) was documented during the 24- to 48-hour period after presentation in 28 infants (17.6%)--one of a total of 18 infants (5.6%) with SBI and 27 of a total of 143 infants (19%) without SBI (alpha, more than .2: power .30). All bacterial isolates in cases of SBI were susceptible to third-generation cephalosporin antibiotics. All repeat blood and urine cultures that were performed in infants with bacteremia or urinary tract infections, respectively, were negative 24 hours after presentation. CONCLUSION Infants 4 to 8 weeks old who remain febrile during the 24 to 48-hour period after presentation and initiation of parenteral antibiotic therapy are less likely to have SBI. This study did not have sufficient power for this difference to be statistically significant.