Using Quality Improvement to Change Testing Practices for Community-acquired Pneumonia.

BACKGROUND: National guidelines for pediatric community-acquired pneumonia (CAP) contain recommendations regarding diagnostic testing including chest radiographs (CXRs), complete blood counts (CBCs), and blood cultures. Local data indicated that our institution was not delivering care at standards outlined by these guidelines. This project aimed to decrease CXRs for children with CAP discharged from the emergency department (ED) by 10% and decrease CBCs and blood cultures for patients hospitalized with uncomplicated CAP by 20% within 1 year. METHODS: This single-site quality improvement initiative targeted otherwise healthy children 3 months to 18 years who presented to the ED with uncomplicated CAP at a free-standing academic children's hospital. A quality improvement team performed a series of interventions including guideline implementation, data sharing, and annual education. Process measures included CXR, CBC, and blood culture rates. Balancing measures included the number of patients diagnosed with CAP, the frequency of antibiotic use, length of stay, and ED and hospital return rates. The team used statistical process control charts to plot measures. RESULTS: There was special cause improvement with a desirable downward shift in testing that correlated with the project's interventions. The percentage of CXRs for discharged patients decreased from 79% to 57%. CBCs and blood cultures for hospitalized patients decreased from 30% to 19% and 24% to 14%, respectively. Balancing measures remained unchanged. CONCLUSIONS: We used elements of quality improvement methodology to reduce testing for uncomplicated CAP without impacting the number of patients diagnosed with CAP, the frequency of antibiotic use, length of stay, and reutilization rates.

Relationship between caloric intake and length of hospital stay for infants with bronchiolitis.

OBJECTIVE: Poor oral intake is a common presenting symptom among infants hospitalized with bronchiolitis. The prevalence, degree, and duration of iminished caloric intake in these infants have not been studied. Our goal was to determine the daily caloric intake among infants admitted with bronchiolitis and to evaluate the relationship between early hospital caloric intake and length of stay (LOS). METHODS: We conducted a retrospective chart review of infants aged <1 year admitted to Children's Hospital of Wisconsin with bronchiolitis who were placed in the bronchiolitis treatment protocol during the 2004-2005 season. Patient-, disease-, respiratory-, and nutrition-specific data were abstracted. RESULTS: A total of 273 patients with bronchiolitis were admitted between November 1, 2004, and April 15, 2005; placed on the bronchiolitis protocol; and included in the study. Median caloric intake was diminished on day 1 (53 kcal/kg per day) and day 2 (64 kcal/kg per day). Caloric intake was slower to normalize in infants with progressively longer LOS, and a slower rate of increase from day 1 to day 2 was significantly correlated with longer LOS (r= -0.18; P= .002). Subgroup analysis revealed significant correlations between hospital day 2 caloric intake and LOS in formula-fed infants, breastfed infants, infants aged <183 days, and infants aged > or =183 days. CONCLUSIONS: Caloric intake was diminished in the early course of hospitalization for infants who had bronchiolitis and slowest to normalize in infants with the longest LOS. Interventions aimed at decreasing LOS among infants admitted with bronchiolitis should consider the potential significance of nutrition for severely affected infants with this condition.

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.

Pediatric hospital medicine: a strategic planning roundtable to chart the future.

Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association sponsored a roundtable to discuss the future of the field. Twenty-one leaders were invited plus a facilitator utilizing established health care strategic planning methods. A "vision statement" was developed. Specific initiatives in 4 domains (clinical practice, quality of care, research, and workforce) were identified that would advance PHM with a plan to complete each initiative. Review of the current issues demonstrated gaps between the current state of affairs and the full vision of the potential impact of PHM. Clinical initiatives were to develop an educational plan supporting the PHM Core Competencies and a clinical practice monitoring dashboard template. Quality initiatives included an environmental assessment of PHM participation on key committees, societies, and agencies to ensure appropriate PHM representation. Three QI collaboratives are underway. A Research Leadership Task Force was created and the Pediatric Research in Inpatient Settings (PRIS) network was refocused, defining a strategic framework for PRIS, and developing a funding strategy. Workforce initiatives were to develop a descriptive statement that can be used by any PHM physician, a communications tool describing "value added" of PHM; and a tool to assess career satisfaction among PHM physicians. We believe the Roundtable was successful in describing the current state of PHM and laying a course for the near future.

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: Children's 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.

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.