Susan Wu

Nebulized Hypertonic Saline for Bronchiolitis: A Randomized Clinical Trial

IMPORTANCE Bronchiolitis is one of the most common and costly respiratory diseases in infants and young children. Previous studies have shown a potential benefit of nebulized hypertonic saline; however, its effect in the emergency department (ED) setting is unclear. OBJECTIVE To compare the effect of nebulized 3% hypertonic saline vs 0.9% normal saline on admission rate and length of stay in infants with bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS We conducted a double-blind, randomized clinical trial during 3 consecutive bronchiolitis seasons from March 1, 2008, through April 30, 2011. We recruited a convenience sample of patients younger than 24 months with a primary diagnosis of viral bronchiolitis presenting to the ED of 2 urban free-standing tertiary childrens hospitals. We excluded patients who were premature (gestational age, <34 weeks) or who had chronic pulmonary disease, immune deficiency, cardiac disease, or previous episodes of wheezing or inhaled bronchodilator use. Of eligible patients who were approached, 161 (26.6%) declined to participate. INTERVENTIONS Patients received 4 mL of 3% sodium chloride (hypertonic saline [HS group]) or 0.9% sodium chloride (normal saline [NS group]) inhaled as many as 3 times in the ED. Those admitted received the assigned medication every 8 hours until discharge. All treatment solutions were premedicated with albuterol sulfate. MAIN OUTCOMES AND MEASURES Hospital admission rate, length of stay for admitted patients, and Respiratory Distress Assessment Instrument score. RESULTS A total of 197 patients were enrolled in the NS group and 211 in the HS group. Admission rate in the 3% HS group was 28.9% compared with 42.6% in the NS group (adjusted odds ratio from logistic regression, 0.49 [95% CI, 0.28-0.86]). Mean (SD) length of stay for hospitalized patients was 3.92 (5.24) days for the NS group and 3.16 (2.11) days for the HS group (P = .24). The Respiratory Distress Assessment Instrument score decreased after treatment in both groups; however, we found no significant difference between groups (P = .35). CONCLUSIONS AND RELEVANCE Hypertonic saline given to children with bronchiolitis in the ED decreases hospital admissions. We can detect no significant difference in Respiratory Distress Assessment Instrument score or length of stay between the HS and NS groups. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00619918.

A multi-institutional medical educational collaborative: advocacy training in California pediatric residency programs.

Educational collaboratives offer a promising approach to disseminate educational resources and provide faculty development to advance residents’ training, especially in areas of novel curricular content; however, their impact has not been clearly described. Advocacy training is a recently mandated requirement of the Accreditation Council for Graduate Medical Education that many programs struggle to meet. The authors describe the formation (in 2007) and impact (from 2008 to 2010) of 13 California pediatric residency programs working in an educational collaboration (“the Collaborative”) to improve advocacy training. The Collaborative defined an overarching mission, assessed the needs of the programs, and mapped their strengths. The infrastructure required to build the collaboration among programs included a social networking site, frequent conference calls, and face-to-face semiannual meetings. An evaluation of the Collaborative’s activities showed that programs demonstrated increased uptake of curricular components and an increase in advocacy activities. The themes extracted from semistructured interviews of lead faculty at each program revealed that the Collaborative (1) reduced faculty isolation, increased motivation, and strengthened faculty academic development, (2) enhanced identification of curricular areas of weakness and provided curricular development from new resources, (3) helped to address barriers of limited resident time and program resources, and (4) sustained the Collaborative’s impact even after formal funding of the program had ceased through curricular enhancement, the need for further resources, and a shared desire to expand the collaborative network.

Improving Home Management Plan of Care Compliance Rates Through an Electronic Asthma Action Plan

Background. In 2007, the Joint Commission mandated reporting of three children’s asthma care (CAC) measures for hospitalized patients with asthma. The third children’s asthma care measure (CAC-3) focuses on hospital discharge with a comprehensive home management plan of care (HMPC) based on the clinical severity. Objective. To improve CAC-3 compliance and identify what interventions would have the most impact. Methods. This was a retrospective observational study, conducted at the Children’s Hospital Los Angeles (CHLA) between October 2008 and January 2012. A total of 470 patients admitted with a primary diagnosis of asthma were included. Four Plan-Do-Study-Act cycles testing separate interventions were used throughout the study period: clinical care coordinators (CCCs), red clipboard for paper HMPC, electronic HMPC, and hard-stop HMPC. Chi-square and binomial tests compared CHLA’s CAC-3 compliance rates within intervention windows as well as to the national average. Results. Between October 2008 and May 2009, CHLA had a compliance rate of 39%, well below the national average (p = .001). Involvement of CCCs increased the overall compliance to 74% (χ2(1) = 11.59, p < .001). Implementation of an electronic HMPC in October 2010 led to the largest increase in overall compliance (93%) when compared to the previous intervention window (χ2(1) = 4.38, p < .036), as well as the national average (p = .016). Compliance rates remained above 90% for four out of the following five quarters. Conclusions.Involvement of CCCs led to a significant increase in the overall CAC-3 compliance. An electronic HMPC improved rates well above the national average. This provides a framework for other institutions that may or may not utilize an electronic medical record.

A Quality Improvement Collaborative to Improve the Discharge Process for Hospitalized Children.

OBJECTIVE: To assess the impact of a quality improvement collaborative on quality and efficiency of pediatric discharges. METHODS: This was a multicenter quality improvement collaborative including 11 tertiary-care freestanding children’s hospitals in the United States, conducted between November 1, 2011 and October 31, 2012. Sites selected interventions from a change package developed by an expert panel. Multiple plan–do–study–act cycles were conducted on patient populations selected by each site. Data on discharge-related care failures, family readiness for discharge, and 72-hour and 30-day readmissions were reported monthly by each site. Surveys of each site were also conducted to evaluate the use of various change strategies. RESULTS: Most sites addressed discharge planning, quality of discharge instructions, and providing postdischarge support by phone. There was a significant decrease in discharge-related care failures, from 34% in the first project quarter to 21% at the end of the collaborative (P < .05). There was also a significant improvement in family perception of readiness for discharge, from 85% of families reporting the highest rating to 91% (P < .05). There was no improvement in unplanned 72-hour (0.7% vs 1.1%, P = .29) and slight worsening of the 30-day readmission rate (4.5% vs 6.3%, P = .05). CONCLUSIONS: Institutions that participated in the collaborative had lower rates of discharge-related care failures and improved family readiness for discharge. There was no significant improvement in unplanned readmissions. More studies are needed to evaluate which interventions are most effective and to assess feasibility in non–children’s hospital settings.

Intravenous Versus Oral Antibiotics for Postdischarge Treatment of Complicated Pneumonia.

BACKGROUND AND OBJECTIVES: Postdischarge treatment of complicated pneumonia includes antibiotics administered intravenously via a peripherally inserted central venous catheter (PICC) or orally. Antibiotics administered via PICC, although effective, may result in serious complications. We compared the effectiveness and treatment-related complications of postdischarge antibiotics delivered by these 2 routes. METHODS: This multicenter retrospective cohort study included children ≥2 months and <18 years discharged with complicated pneumonia between 2009 and 2012. The main exposure was the route of postdischarge antibiotic administration, classified as PICC or oral. The primary outcome was treatment failure. Secondary outcomes included PICC complications, adverse drug reactions, other related revisits, and a composite of all 4 outcomes, termed “all related revisits.” RESULTS: Among 2123 children, 281 (13.2%) received antibiotics via PICC. Treatment failure rates were 3.2% among PICC and 2.6% among oral antibiotic recipients and were not significantly different between the groups in across-hospital-matched analysis (matched odds ratio [OR], 1.26; 95% confidence interval [CI], 0.54 to 2.94). PICC complications occurred in 7.1%. Adverse drug reactions occurred in 0.6% of children; PICC antibiotic recipients had greater odds of adverse drug reaction in across hospital matched analysis (matched OR, 19.1; 95% CI, 4.2 to 87.3). The high rate of PICC complications and differences in adverse drug reactions contributed to higher odds of the composite outcome of all related revisits among PICC antibiotic recipients (matched OR, 4.71; 95% CI, 2.97 to 7.46). CONCLUSIONS: Treatment failure rates between PICC and oral antibiotics did not differ. Children with complicated pneumonia should preferentially receive oral antibiotics at discharge when effective oral options are available.

Dispensing Pattern of Generic and Brand-Name Drugs in Children

OBJECTIVE To describe the dispensing patterns of generic and brand-name drugs in children and to identify patient sociodemographic characteristics associated with generic drug use. METHODS We analyzed data from the 2002 Medical Expenditures Panel Survey. This survey is conducted by the Agency for Healthcare Research and Quality and consists of a nationally representative sample of civilian noninstitutionalized population of the United States. The 2002 survey included 14 828 families and 37 418 individuals, 11 099 of whom were children 0 to 17 years of age. Our unit of analysis was individual prescription drugs dispensed to children 0 to 17 years of age. The main dependent variable for the logistic model was the use of generic drugs. Independent variables included age, gender, race, insurance type, family income, Metropolitan Statistical Area status, and health status. RESULTS Generic drugs were filled in 40.6% of the 24 465 prescriptions analyzed. Average expenditure for generic drugs was

Care Variations and Outcomes for Children Hospitalized With Bacterial Tracheostomy-Associated Respiratory Infections.

20.92 (SD 24.53) per prescription versus

Association Between Pediatric Home Management Plan of Care Compliance and Asthma Readmission.

71.65 (SD

When Intensive Care Is Too Intense: Variations in Standard Practices Across Hospital Acuity Levels

170.22) for brand-name drugs. Use of generic versus brand-name drugs varied by conditions and medication class. Uninsured patients were more likely than privately insured patients to have a generic drug dispensed than brand-name drugs (odds ratio [OR] 1.42; 95% confidence interval [CI], 1.10-1.84). Asian children were more likely than white children to receive generic drugs (OR, 1.66; 95% CI, 1.07-2.57). Girls were also more likely than boys to receive generic drugs over brand-name drugs (OR, 1.36; 95% CI, 1.08-1.73). CONCLUSIONS Generic drugs were dispensed more often to uninsured children, Asian children, and girls.

Length of Stay and Hospital Revisit After Bacterial Tracheostomy–Associated Respiratory Tract Infection Hospitalizations

OBJECTIVES Identify hospital-level care variations and association with length of stay (LOS) and hospital revisit in children with tracheostomies hospitalized for bacterial respiratory tract infections (bRTIs). METHODS A multicenter, retrospective cohort study that used the Pediatric Health Information System database between 2007 and 2014 of patients with tracheostomies aged ≤18 years with a primary diagnosis of bRTI (eg, tracheitis) or a primary diagnosis of a bRTI symptom (eg, cough) and a secondary diagnosis of bRTI. Primary outcomes were LOS and 30-day all-cause revisit rates. Secondary outcomes included hospital-level diagnostic testing and anti-Pseudomonas antibiotic use. We used mixed-effects negative binomial (for LOS) and logistic (for revisit) regression to explore the relationship between hospital-level diagnostic test utilization and the outcomes. RESULTS Data representing 4137 unique patients with a median age of 3 years (interquartile range: 1-9 years) were included. Median LOS was 4 days (interquartile range: 3-8 days), and the 30-day revisit rate was 24.9%. Use of diagnostic testing and empirical anti-Pseudomonas antibiotics varied significantly among hospitals (all P values <.001). After adjusting for patient and hospital characteristics, compared with low test utilization hospitals, there were no differences in 30-day all-cause revisit rates in moderate (adjusted odds ratio: 1.19; 95% confidence interval [CI]: 0.93-1.52) or high (adjusted odds ratio: 1.07; 95% CI: 0.82-1.39) utilization hospitals. LOS in hospitals with moderate (% difference: -0.8%; 95% CI: -14.4-14.9%) or high (% difference: 13.9%; 95% CI: -0.7-30.6%) test utilization was not significantly longer. CONCLUSIONS Given that care variations were not associated with outcomes, future research should focus on standardizing diagnosis and treatment of bRTIs and readmission prevention in this population.