Samir S. Shah

The Family Perspective on Hospital to Home Transitions: A Qualitative Study

BACKGROUND AND OBJECTIVE: Transitions from the hospital to home can be difficult for patients and families. Family-informed characterization of this vulnerable period may facilitate the identification of interventions to improve transitions home. Our objective was to develop a comprehensive understanding of hospital-to-home transitions from the family perspective. METHODS: Using qualitative methods, focus groups and individual interviews were held with caregivers of children discharged from the hospital in the preceding 30 days. Focus groups were stratified based upon socioeconomic status. The open-ended, semistructured question guide included questions about communication and understanding of care plans, transition home, and postdischarge events. Using inductive thematic analysis, investigators coded the transcripts, resolving differences through consensus. RESULTS: Sixty-one caregivers participated across 11 focus groups and 4 individual interviews. Participants were 87% female and 46% nonwhite; 38% were the only adult in their household, and 56% resided in census tracts with ≥15% of residents living in poverty. Responses from participants yielded a conceptual model depicting key elements of families’ experiences with hospital-to-home transitions. Four main concepts resulted: (1) “In a fog” (barriers to processing and acting on information), (2) “What I wish I had” (desired information and suggestions for improvement), (3) “Am I ready to go home?” (discharge readiness), and (4) “I’m home, now what?” (confidence and postdischarge care). CONCLUSIONS: Transitions from hospital to home affect the lives of families in ways that may affect patient outcomes postdischarge. The caregiver is key to successful transitions, and the family perspective can inform interventions that support families and facilitate an easier re-entry to the home.

Computed tomography and shifts to alternate imaging modalities in hospitalized children

BACKGROUND: Many studies have demonstrated a rise in computed tomography (CT) utilization in children’s hospitals. However, CT utilization may be declining, perhaps due to awareness of potential hazards of pediatric ionizing radiation, such as increased risk of malignancy. The objective is to assess the trend in CT utilization in hospitalized children at freestanding children’s hospitals from 2004 to 2012 and we hypothesize decreases are associated with shifts to alternate imaging modalities. METHODS: Multicenter cross-sectional study of children admitted to 33 pediatric tertiary-care hospitals participating in the Pediatric Health Information System between January 1, 2004, and December 31, 2012. The rates of CT, ultrasound, and MRI for the top 10 All-Patient Refined Diagnosis Related Groups (APR-DRGs) for which CT was performed in 2004 were determined by billing data. Rates of each imaging modality for those top 10 APR-DRGs were followed through the study period. Odds ratios of imaging were adjusted for demographics and illness severity. RESULTS: For all included APR-DRGs except ventricular shunt procedures and nonbacterial gastroenteritis, the number of children imaged with any modality increased. CT utilization decreased for all APR-DRGs (P values < .001). For each of the APR-DRGs except seizure and infections of upper respiratory tract, the decrease in CT was associated with a significant rise in an alternative imaging modality (P values ≤ .005). CONCLUSIONS: For the 10 most common APR-DRGs for which children received CT in 2004, a decrease in CT utilization was found in 2012. Alternative imaging modalities for 8 of the diagnoses were used.

Trends in intravenous antibiotic duration for urinary tract infections in young infants

The proportion of infants ≤60 days old receiving long-duration IV antibiotics for UTIs has decreased between 2005 and 2015 and varies by children’s hospital. OBJECTIVES: To assess trends in the duration of intravenous (IV) antibiotics for urinary tract infections (UTIs) in infants ≤60 days old between 2005 and 2015 and determine if the duration of IV antibiotic treatment is associated with readmission. METHODS: Retrospective analysis of infants ≤60 days old diagnosed with a UTI who were admitted to a children’s hospital and received IV antibiotics. Infants were excluded if they had a previous surgery or comorbidities, bacteremia, or admission to the ICU. Data were analyzed from the Pediatric Health Information System database from 2005 through 2015. The primary outcome was readmission within 30 days for a UTI. RESULTS: The proportion of infants ≤60 days old receiving 4 or more days of IV antibiotics (long IV treatment) decreased from 50% in 2005 to 19% in 2015. The proportion of infants ≤60 days old receiving long IV treatment at 46 children’s hospitals varied between 3% and 59% and did not correlate with readmission (correlation coefficient 0.13; P = .37). In multivariable analysis, readmission for a UTI was associated with younger age and female sex but not duration of IV antibiotic therapy (adjusted odds ratio for long IV treatment: 0.93 [95% confidence interval 0.52–1.67]). CONCLUSIONS: The proportion of infants ≤60 days old receiving long IV treatment decreased substantially from 2005 to 2015 without an increase in hospital readmissions. These findings support the safety of short-course IV antibiotic therapy for appropriately selected neonates.

Testing and Empiric Treatment for Neonatal Herpes Simplex Virus: Challenges and Opportunities for Improving the Value of Care.

A 6-day-old boy presents to the emergency department with 1 day of fever and decreased intake. He has no rash, is mildly dehydrated but not ill-appearing, and has normal mental status. An evaluation for serious bacterial infection is performed, but the lumbar puncture is not successful. He receives ampicillin and gentamicin and is admitted to the inpatient unit. The resident team successfully reattempts the lumbar puncture, with 6 white blood cells and >1000 red blood cells. Herpes simplex virus testing of the cerebrospinal fluid and mucous membranes is sent, the patient is started on acyclovir, and his gentamicin is changed to cefotaxime to minimize exposure to nephrotoxic medications. On day 2 of hospitalization, the team notes that his creatinine has increased since admission. This prompts initiation of intravenous fluids and repeat laboratory testing. The parents ask about the potential impact on his future kidney function. The herpes simplex virus testing and all cultures are negative; however, discharge is delayed as repeat creatinine measurements are performed to ensure the creatinine is decreasing.nnNeonatal herpes simplex virus (HSV) infections are rare, with an incidence of 9.6 per 100 000 births1 and a prevalence of 0.2% to 0.3% in febrile neonates.2 However, neonatal HSV infections are associated with high mortality and, among survivors, long-term morbidity.3,4 In the absence of multicenter trials and decision rules, clinicians must rely on findings from published case series, which emphasize that no combination of presenting signs and symptoms can reliably identify all neonates with HSV infection.5–11 The variability in presentation has given rise to multiple proposed approaches to empiric testing and treatment and, consequently, substantial variation in the factors that prompt HSV testing, sometimes without clear correlation with known risk factors.12–15nnIt is important to address this …

Educational Added Value Unit: Development and Testing of a Measure for Educational Activities.

OBJECTIVESnUniversity-based hospitalists educate health care professionals as an expectation, often lacking time and support for these activities. The purpose of this study was to (1) develop a tracking tool to record educational activities, (2) demonstrate its applicability and ease of completion for faculty members in different divisions, and (3) compare educational efforts of individuals from different professional pathways and divisions by using the educational added value unit (EAVU).nnnMETHODSnEducational activities were selected and ranked according to preparation effort, presentation time, and impact to calculate the EAVU. Faculty participants from 5 divisions at 1 institution (hospital medicine, general and community pediatrics, emergency medicine, behavior medicine and clinical psychology, and biostatistics and epidemiology) completed the retrospective, self-report tracking tool.nnnRESULTSnA total of 62% (74 of 119) of invited faculty members participated. All faculty earned some EAVUs; however, there was a wide distribution range. The median EAVU varied by division (hospital medicine [21.7], general and community pediatrics [20.6], emergency medicine [26.1], behavior medicine and clinical psychology [18.3], and biostatistics and epidemiology [8.2]). Faculty on the educator pathway had a higher median EAVU compared with clinical or research pathways.nnnCONCLUSIONSnThe EAVU tracking tool holds promise as a mechanism to track educational activities of different faculty pathways. EAVU collection could be of particular benefit to hospitalists, who often perform unsupported teaching activities. Additional studies are needed to determine how to apply a similar process in different institutions and to determine how EAVUs could be used for additional support for teaching, curriculum development, and educational scholarship.

Biomarkers for Predicting Illness Severity in Children With Acute Lower Respiratory Tract Infections.

Acute lower respiratory tract infections (LRTIs), such as bronchiolitis and pneumonia, account for a substantial proportion of pediatric hospitalizations and health resource utilization [1]. Despite the availability of national guidelines, there remains substantial variation in emergency department and inpatient management for children with these conditions, particularly with regards to ancillary testing and hospitalization decisions [2–4]. Such practice variation highlights the uncertainty among pediatricians in assessing the severity of illness of children with common acute LRTIs. Biological markers, or biomarkers, have been proposed as objective measures of disease onset or progression to inform clinical decision making. In this issue of the Journal of the Pediatric Infectious Diseases Society, Beigelman et al [5] used a prospective cohort study design to evaluate the association of vitamin D and illness severity among children with bronchiolitis caused by respiratory syncytial virus (RSV). Vitamin D deficiency in cord blood (serum vitamin D levels below 20 ng/mL) has been associated with development of RSV bronchiolitis in the first year of life in a small birth cohort of infants [6]. Furthermore, serum vitamin D levels are of interest as biomarkers in patients with LRTIs, in part, because of the role of vitamin D in modulating the innate immune response. The active form of vitamin D, 1,25 (OH)2D, induces the production of antimicrobial peptides including cathelicidin and β-defensin 2. These peptides disrupt bacterial cell membranes, attract other inflammatory cells, and contribute to wound repair [7]. Relevant to viral LRTIs, vitamin D has also been implicated in modifying the signaling pathways that bind respiratory viruses. For example, 1,25-dihydroxyvitamin D decreases the expression of intercellular adhesion molecule-1, the major cellular receptor for human rhinovirus [8]. Beigelman et al [5] enrolled infants 12 months and younger with RSV bronchiolitis. Unlike most previous studies, which measured vitamin D levels in cord blood, vitamin D levels were measured at hospital admission in 145 infants, thereby indicating vitamin D status at the time of the bronchiolitis episode. Clinical outcomes such as length of hospitalization, lowest oxygen saturation during hospitalization, and the Bronchiolitis Severity Score at admission were not significantly associated with vitamin D levels or with vitamin D deficiency (using categorical cutoffs of either <20 ng/mL or <30 ng/mL) when adjusting for either age or formula consumption. Although this study suggests that vitamin D may not be an optimal biomarker to predict RSV disease severity, the study had several limitations and raises additional questions. The prevalence of vitamin D deficiency, although consistent with that expected in the United States, was relatively low ( 10%), making it possible that the study was underpowered to detect important differences in outcomes; a power calculation was not provided to inform interpretation of the results. In addition, although duration of hospitalization is commonly used as a proxy for illness severity, discharge decisions are often subjective and may be influenced by nonclinical factors, limiting the utility of this measure as a proxy for illness severity. Standardized discharge criteria or time to clinical stability, both of which have been described for respiratory illness [9, 10], may serve as more objective measures. Accurate assessment and prediction of disease severity is critical to the effective management of children with Editorial Commentary