Stuart T. Weinberg

Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years

OBJECTIVE: To update the American Academy of Pediatrics clinical practice guideline regarding the diagnosis and management of acute bacterial sinusitis in children and adolescents. METHODS: Analysis of the medical literature published since the last version of the guideline (2001). RESULTS: The diagnosis of acute bacterial sinusitis is made when a child with an acute upper respiratory tract infection (URI) presents with (1) persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement), (2) a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement), or (3) severe onset (concurrent fever [temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days). Clinicians should not obtain imaging studies of any kind to distinguish acute bacterial sinusitis from viral URI, because they do not contribute to the diagnosis; however, a contrast-enhanced computed tomography scan of the paranasal sinuses should be obtained whenever a child is suspected of having orbital or central nervous system complications. The clinician should prescribe antibiotic therapy for acute bacterial sinusitis in children with severe onset or worsening course. The clinician should either prescribe antibiotic therapy or offer additional observation for 3 days to children with persistent illness. Amoxicillin with or without clavulanate is the first-line treatment of acute bacterial sinusitis. Clinicians should reassess initial management if there is either a caregiver report of worsening (progression of initial signs/symptoms or appearance of new signs/symptoms) or failure to improve within 72 hours of initial management. If the diagnosis of acute bacterial sinusitis is confirmed in a child with worsening symptoms or failure to improve, then clinicians may change the antibiotic therapy for the child initially managed with antibiotic or initiate antibiotic treatment of the child initially managed with observation. CONCLUSIONS: Changes in this revision include the addition of a clinical presentation designated as “worsening course,” an option to treat immediately or observe children with persistent symptoms for 3 days before treating, and a review of evidence indicating that imaging is not necessary in children with uncomplicated acute bacterial sinusitis.

Standards for health information technology to ensure adolescent privacy

Privacy and security of health information is a basic expectation of patients. Despite the existence of federal and state laws safeguarding the privacy of health information, health information systems currently lack the capability to allow for protection of this information for minors. This policy statement reviews the challenges to privacy for adolescents posed by commercial health information technology systems and recommends basic principles for ideal electronic health record systems. This policy statement has been endorsed by the Society for Adolescent Health and Medicine.

Improving Influenza Vaccination Rates of High-Risk Inner-City Children Over 2 Intervention Years

PURPOSE Influenza immunization rates among children with high-risk medical conditions are disappointingly low, and relatively few data are available on raising rates, particularly over 2 years. We wanted to determine whether interventions tailored to individual practice sites improve influenza immunization rates among high-risk children in inner-city health centers over 2 years. METHOD A before-after trial to improve influenza immunization of children was conducted at 5 inner-city health centers (residencies and faith-based). Sites selected interventions from a menu (eg, standing orders, patient and clinician reminders, education) proved to increase vaccination rates, which were directed at children aged 2 to 17 years with high-risk medical conditions. Intervention influenza vaccination rates and 1 and 2 years were compared with those of the preintervention year (2001–2002) and of a comparison site. RESULTS Influenza vaccination rates improved modestly from baseline (10.4%) to 13.1% during intervention year 1 and to 18.7% during intervention year 2 (P <.001), with rates reaching 31% in faith-based practices. Rates increased in all racial and age-groups and in Medicaid-insured children. The increase in rates was significantly greater in intervention health centers (8.3%) than in the comparison health center (0.7%; P <.001). In regression analyses that controlled for demographic factors, vaccination status was associated with intervention year 1 (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.6–2.2) and with intervention year 2 (OR, 2.8; 95% CI, 2.3–3.4), as well as with practice type. Adolescents had lower vaccination rates than children 2 to 6 years old (OR, 0.6; 95% CI, 0.5–0.7). CONCLUSIONS Tailored interventions selected from a menu of interventions modestly increased influenza vaccination rates over 2 years at health centers serving children from low-income families. We recommend this strategy for faith-based practices and residencies with 1 practice site, but further research is needed on multisite practices and to achieve higher influenza vaccination rates.

Automated Dose-Rounding Recommendations for Pediatric Medications

BACKGROUND: Although pediatric electronic prescribing systems are increasingly being used in pediatric care, many of these systems lack the clinical decision-support infrastructure needed to calculate a safe and effective rounded medication dose. This infrastructure is required to facilitate tailoring of established dosing guidance while maintaining the medications therapeutic intent. OBJECTIVE: The goal of this project was to establish best practices for generating an appropriate medication dose and to create an interoperable rounding knowledge base combining best practices and dose-rounding information. METHODS: We interviewed 19 pediatric health care and pediatric pharmacy experts and conducted a literature review. After using these data to construct initial rounding tolerances, we used a Delphi process to achieve consensus about the rounding tolerance for each commonly prescribed medication. RESULTS: Three categories for medication-rounding philosophy emerged from our literature review: (1) medications for which rounding is used judiciously to retain the intended effect; (2) medications that are rounded with attention to potential unintended effects; and (3) medications that are rarely rounded because of the potential for toxicity. We assigned a small subset of medications to a fourth category—inadequate data—for which there was insufficient information to provide rounding recommendations. For all 102 medications, we were able to arrive at a consensus recommendation for rounding a given calculated dose. CONCLUSIONS: Results of this study provide the pediatric information technology community with a primary set of recommended rounding tolerances for commonly prescribed drugs. The interoperable knowledge base developed here can be integrated with existing and developing electronic prescribing systems, potentially improving prescribing safety and reducing cognitive workload.

Central Nervous System Manifestations of Sarcoidosis in Children: Case Report and Review

We report a case of central nervous system (CNS) sarcoidosis in a young girl and review the literature on the CNS manifestations of sarcoidosis in 23 cases occurring in children.

Policy statement - Recommendations for the prevention and treatment of influenza in children, 2009-2010

The purpose of this statement is to update current recommendations for routine use of trivalent seasonal influenza vaccine and antiviral medications for the prevention and treatment of influenza in children.

Evaluation of Computerized Free Text Sign-Out Notes Baseline Understanding and Recommendations

BACKGROUND: Standardization of sign-out, the transfer of patient information and responsibility between inpatient providers at shift change, is a Joint Commission National Patient Safety Goal intended to improve communication and reduce risk of error. Computerized systems with free text data entry and limited structure allow clinicians to generate sign-out notes in a variety of ways. OBJECTIVES: The literature lacks a systematic exploration of the range of content generated by users of computerized sign-out systems. The goal of this study was to determine if and how clinicians record standardized sign-out information using a system with free text data entry and limited structure. METHODS: Using qualitative methods, we reviewed free text sign-out notes for 730 patient cases across 39 hospital units at an academic medical center. RESULTS: Two categories of information expression emerged from analysis: patient treatment-comprised of patient summaries, awareness items, and action items-and care team coordination-consisting of discharge information, contact information, and social concerns. A third category describing the format of sign-out note content, presentation of information, also emerged. Location and structure of information varied, but sign-out note content for some hospital units exhibited specific characteristics and was relatively standardized. CONCLUSIONS: Findings provide a baseline understanding of computerized free text sign-out note content. Sign-out notes contained a synthesis of data from disparate sources. We recommend formalizing existing unit-specific content standardization and system use patterns to reduce sign-out note variability and improve communication.

Electronic prescribing in pediatrics

This policy statement identifies the potential value of electronic prescribing (e-prescribing) systems in improving quality and reducing harm in pediatric health care. On the basis of limited but positive pediatric data and on the basis of federal statutes that provide incentives for the use of e-prescribing systems, the American Academy of Pediatrics recommends the adoption of e-prescribing systems with pediatric functionality. The American Academy of Pediatrics also recommends a set of functions that technology vendors should provide when e-prescribing systems are used in environments in which children receive care.

Screening Tool Predicts Future Underimmunization Among a Pediatric Practice in Tennessee

The Parent Attitudes about Childhood Vaccines (PACV) survey for identifying vaccine-hesitant parents was recently validated in Washington State but did not include all recommended childhood vaccines. The current study compares vaccination rates for all recommended childhood vaccines and PACV scores at one pediatric practice in Tennessee. Children were enrolled at the 2-week well visit, and vaccination rates were assessed at 19 months of age. Outcomes at 19 months of age included mean percentage of days underimmunized and up-to-date status (yes/no) compared with PACV scores. The impact of provider on immunization status was assessed. Complete vaccination data were available for 158 children of 183 enrolled (86%). Higher PACV scores were associated with more days underimmunized (P < .001) and being overdue for vaccine doses at 19 months of age (P < .001). No difference was seen between providers and up-to-date status. Our study supports the predictive validity of the PACV for underimmunization.

Assessing the reliability of an automated dose-rounding algorithm

OBJECTIVE Pediatric dose rounding is a unique and complex process whose complexity is rarely supported by e-prescribing systems, though amenable to automation and deployment from a central service provider. The goal of this project was to validate an automated dose-rounding algorithm for pediatric dose rounding. METHODS We developed a dose-rounding algorithm, STEPSTools, based on expert consensus about the rounding process and knowledge about the therapeutic/toxic window for each medication. We then used a 60% subsample of electronically-generated prescriptions from one academic medical center to further refine the web services. Once all issues were resolved, we used the remaining 40% of the prescriptions as a test sample and assessed the degree of concordance between automatically calculated optimal doses and the doses in the test sample. Cases with discrepant doses were compiled in a survey and assessed by pediatricians from two academic centers. The response rate for the survey was 25%. RESULTS Seventy-nine test cases were tested for concordance. For 20 cases, STEPSTools was unable to provide a recommended dose. The dose recommendation provided by STEPSTools was identical to that of the test prescription for 31 cases. For 14 out of the 24 discrepant cases included in the survey, respondents significantly preferred STEPSTools recommendations (p<0.05, binomial test). Overall, when combined with the data from all test cases, STEPSTools either matched or exceeded the performance of the test cases in 45/59 (76%) of the cases. The majority of other cases were challenged by the need to provide an extremely small dose. We estimated that with the addition of two dose-selection rules, STEPSTools would achieve an overall performance of 82% or higher. CONCLUSIONS Results of this pilot study suggest that automated dose rounding is a feasible mechanism for providing guidance to e-prescribing systems. These results also demonstrate the need for validating decision-support systems to support targeted and iterative improvement in performance.