Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value.

BACKGROUND: Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under-recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric work group's results. METHODS: A work group of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below. RESULTS: The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. CONCLUSION: We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care.

Caveats for the use of operational electronic health record data in comparative effectiveness research.

The growing amount of data in operational electronic health record systems provides unprecedented opportunity for its reuse for many tasks, including comparative effectiveness research. However, there are many caveats to the use of such data. Electronic health record data from clinical settings may be inaccurate, incomplete, transformed in ways that undermine their meaning, unrecoverable for research, of unknown provenance, of insufficient granularity, and incompatible with research protocols. However, the quantity and real-world nature of these data provide impetus for their use, and we develop a list of caveats to inform would-be users of such data as well as provide an informatics roadmap that aims to insure this opportunity to augment comparative effectiveness research can be best leveraged.

Peripheral intravenous access in pediatric inpatients.

BACKGROUND: Peripheral intravenous (PIV) line placement is a time-consuming procedure performed on the majority of general pediatric inpatients, with significant discomfort to patients. OBJECTIVE: To determine parameters of pediatric PIV placement, including success rates, time to success, and factors associated with success. DESIGN: Prospective study involving direct observation of PIV placement by trained research staff. SETTING: General inpatient wards at 2 medium-sized pediatric hospitals. PATIENTS: Hospitalized children younger than 19 years. RESULTS: Successful placement was achieved in 95.8% (567/592) cases with a median time of 9 minutes. Children younger than 2 years were less likely to have success on the first attempt (38.9% vs 53.5%) and have longer time to success (11 minutes). CONCLUSIONS: Children younger than 2 years experienced lower first-attempt successful PIV placement and took longer. The overall success rate was similar to prior reports; these data are the first to show differential PIV success by patient age.