Addressing food insecurity in the inpatient setting: Results of a postdischarge pilot study.

BACKGROUND AND OBJECTIVES: With a growing interest in screening for food insecurity (FI) during pediatric hospitalization, there is a parallel need to develop interventions. With input from caregivers experiencing FI, we sought to identify interventions to assist with short-term FI after discharge and evaluate their feasibility, acceptability, and appropriateness. METHODS: We first employed qualitative methods to identify potential interventions. Next, we conducted a pilot study of selected interventions for families experiencing FI. Seven days postdischarge, caregivers rated the intervention's feasibility, acceptability, and appropriateness. We also assessed for ongoing FI. We summarized the median and proportion of "completely agree" responses to feasibility, acceptability, and appropriateness questions, and we compared in-hospital and postdischarge FI using McNemar's test. RESULTS: In the qualitative stage, 14 caregivers prioritized three interventions: grocery store gift cards, grocery delivery/pick-up, and frozen meals. In the pilot study, 53 caregivers (25% of those screened) endorsed FI during their child's hospitalization and received one or more of the interventions. Every caregiver selected the grocery gift card option; 37 families (69.8%) also received frozen meals. Seven days after discharge, most caregivers rated the intervention as "completely" feasible (76%), acceptable (90%), and appropriate (88%). There was a significant decrease in caregivers who reported FI after discharge compared to during the hospitalization (p < .001). CONCLUSIONS: This study demonstrates the feasibility, acceptability, and appropriateness of inpatient interventions to address FI, particularly at the time of pediatric hospital discharge and transition home. Randomized trials are needed to further evaluate the efficacy of interventions employed during hospitalization.

Association Between Gender and Salary Among Pediatric Hospital Medicine Physicians.

OBJECTIVES: Gender-based disparities in salary exist in multiple fields of medicine. However, there is limited data examining gender inequities in salary in pediatric hospital medicine (PHM). Our primary objective was to assess whether gender-based salary differences exist in PHM. The secondary objective was to assess if, among women, the differences in salary varied on the basis of leadership positions or self-identified race and ethnicity. METHODS: We conducted a survey-based, cross-sectional study of pediatric hospitalists in December 2021. Our primary outcomes were base and total salary, adjusted for the reported number of average weekly work hours. We performed subanalyses by presence of a leadership position, as well as race. We used a weighted t test using inverse probability weighting to compare the outcomes between genders. RESULTS: A total of 559 eligible people responded to our survey (51.0%). After propensity score weighting, women's mean base salary was 87.7% of men's base (95% confidence interval [CI] 79.8%-96.4%, P < .01), and women's total salary was 85.6% of men's total (95% CI 73.2%-100.0%, P = .05) salary. On subgroup analysis of respondents with a leadership position, women's total salary was 80.6% of men's total salary (95% CI 68.7%-94.4%, P < .01). Although women who identified as white had base salaries that were 86.6% of white men's base salary (95% CI 78.5%-95.5%, P < .01), there was no gender-based difference noted between respondents that identified as nonwhite (88.4% [69.9%-111.7%] for base salary, 80.3% [57.2% to 112.7%]). CONCLUSIONS: Gender-based discrepancies in salary exists in PHM, which were increased among those with leadership roles. Continued work and advocacy are required to achieve salary equity within PHM.

Increasing the Use of Enteral Antibiotics in Hospitalized Children With Uncomplicated Infections.

BACKGROUND: Route of administration is an important component of antimicrobial stewardship. Early transition from intravenous to enteral antibiotics in hospitalized children is associated with fewer catheter-related adverse events, as well as decreased costs and length of stay. Our aim was to increase the percentage of enteral antibiotic doses for hospital medicine patients with uncomplicated common bacterial infections (community-acquired pneumonia, skin and soft tissue infection, urinary tract infection, neck infection) from 50% to 80% in 6 months. METHODS: We formed a multidisciplinary team to evaluate key drivers and design plan-do-study-act cycles. Interventions included provider education, structured discussion at existing team huddles, and pocket-sized printed information. Our primary measure was the percentage of antibiotic doses given enterally to patients receiving other enteral medications. Secondary measures included antibiotic cost, number of peripheral intravenous catheters, length of stay, and 7-day readmission. We used statistical process control charts to track our measures. RESULTS: Over a 6-month baseline period and 12 months of improvement work, we observed 3183 antibiotic doses (888 in the baseline period, 2295 doses during improvement work). We observed an increase in the percentage of antibiotic doses given enterally per week for eligible patients from 50% to 67%. We observed decreased antibiotic costs and fewer peripheral intravenous catheters per encounter after the interventions. There was no change in length of stay or readmissions. CONCLUSIONS: We observed increased enteral antibiotic doses for children hospitalized with common bacterial infections. Interventions targeting culture change and communication were associated with sustained improvement.

Getting Started With Multi-site Research: Lessons From the Eliminating Monitor Overuse (EMO) Study.

Research in Pediatric Hospital Medicine is growing and expanding rapidly, and with this comes the need to expand single-site research projects into multisite research studies within practice-based research networks. This expansion is crucial to ensure generalizable findings in diverse populations; however, expanding Pediatric Hospital Medicine research projects from single to multisite can be daunting. We provide an overview of major logistical steps and challenges in project management, regulatory approvals, data use agreements, training, communication, and financial management that are germane to hospitalist researchers launching their first multisite project by sharing processes and lessons learned from running multisite research projects in the Pediatric Research in Inpatient Settings Network within the Eliminating Monitor Overuse study portfolio. This description is relevant to hospitalist researchers transitioning from single-site to multisite research or those considering serving as site lead for a multisite project.

Epidemiology and Severity of Illness of MIS-C and Kawasaki Disease During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Multisystem inflammatory syndrome in children (MIS-C) is a novel, severe condition following severe acute respiratory syndrome coronavirus 2 infection. Large epidemiologic studies comparing MIS-C to Kawasaki disease (KD) and evaluating the evolving epidemiology of MIS-C over time are lacking. We sought to understand the illness severity of MIS-C compared with KD and evaluate changes in MIS-C illness severity over time during the coronavirus disease 2019 pandemic compared with KD. METHODS: We included hospitalizations of children with MIS-C and KD from April 2020 to May 2022 from the Pediatric Health Information System administrative database. Our primary outcome measure was the presence of shock, defined as the use of vasoactive/inotropic cardiac support or extracorporeal membrane oxygenation. We examined the volume of MIS-C and KD hospitalizations and the proportion of hospitalizations with shock over time using 2-week intervals. We compared the proportion of hospitalizations with shock in MIS-C and KD patients over time using generalized estimating equations adjusting for hospital clustering and age, with time as a fixed effect. RESULTS: We identified 4868 hospitalizations for MIS-C and 2387 hospitalizations for KD. There was a higher proportion of hospitalizations with shock in MIS-C compared with KD (38.7% vs 5.1%). In our models with time as a fixed effect, we observed a significant decrease in the odds of shock over time in MIS-C patients (odds ratio 0.98, P < .001) but not in KD patients (odds ratio 1.00, P = .062). CONCLUSIONS: We provide further evidence that MIS-C is a distinct condition from KD. MIS-C was a source of lower morbidity as the pandemic progressed.

Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial: Statistical analysis plan.

Background: Deimplementing overused health interventions is essential to maximizing quality and value while minimizing harm, waste, and inefficiencies. Three national guidelines discourage continuous pulse oximetry (SpO2) monitoring in children who are not receiving supplemental oxygen, but the guideline-discordant practice remains prevalent, making it a prime target for deimplementation. This paper details the statistical analysis plan for the Eliminating Monitor Overuse (EMO) SpO2 trial, which compares the effect of two competing deimplementation strategies (unlearning only vs. unlearning plus substitution) on the sustainment of deimplementation of SpO2 monitoring in children with bronchiolitis who are in room air. Methods: The EMO Trial is a hybrid type 3 effectiveness-deimplementation trial with a longitudinal cluster-randomized design, conducted in Pediatric Research in Inpatient Settings Network hospitals. The primary outcome is deimplementation sustainment, analyzed as a longitudinal difference-in-differences comparison between study arms. This analysis will use generalized hierarchical mixed-effects models for longitudinal clustering outcomes. Secondary outcomes include the length of hospital stay and oxygen supplementation duration, modeled using linear mixed-effects regressions. Using the well-established counterfactual approach, we will also perform a mediation analysis of hospital-level mechanistic measures on the association between the deimplementation strategy and the sustainment outcome. Discussion: We anticipate that the EMO Trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, and likelihood of sustained practice change using rigorously designed deimplementation strategies. This pre-specified statistical analysis plan will mitigate reporting bias and support data-driven approaches. Trial registration: ClinicalTrials.gov NCT05132322. Registered on 24 November 2021.

Sustainment of continuous pulse oximetry deimplementation: Analysis of Eliminating Monitor Overuse study data from six hospitals.

Using continuous pulse oximetry (cSpO2 ) to monitor children with bronchiolitis who are not receiving supplemental oxygen is a form of medical overuse. In this longitudinal analysis from the Eliminating Monitor Overuse (EMO) study, we aimed to assess changes in cSpO2 overuse before, during, and after intensive cSpO2 -deimplementation efforts in six hospitals. Monitoring data were collected during three phases: "P1" baseline, "P2" active deimplementation (all sites engaged in education and audit and feedback strategies), and "P3" sustainment (a new baseline measured after strategies were withdrawn). Two thousand and fifty-three observations were analyzed. We found that each hospital experienced reductions during active deimplementation (P2), with overall adjusted cSpO2 overuse decreasing from 53%, 95% confidence interval (CI): (49-57) to 22%, 95% CI: (19-25) between P1 and P2. However, following the withdrawal of deimplementation strategies, overuse rebounded in all six sites, with overall adjusted cSpO2 overuse increasing to 37%, 95% CI: (33-41) in P3.

Identifying and Validating Pediatric Hospitalizations for MIS-C Through Administrative Data.

BACKGROUND: Individual children's hospitals care for a small number of patients with multisystem inflammatory syndrome in children (MIS-C). Administrative databases offer an opportunity to conduct generalizable research; however, identifying patients with MIS-C is challenging. METHODS: We developed and validated algorithms to identify MIS-C hospitalizations in administrative databases. We developed 10 approaches using diagnostic codes and medication billing data and applied them to the Pediatric Health Information System from January 2020 to August 2021. We reviewed medical records at 7 geographically diverse hospitals to compare potential cases of MIS-C identified by algorithms to each participating hospital's list of patients with MIS-C (used for public health reporting). RESULTS: The sites had 245 hospitalizations for MIS-C in 2020 and 358 additional MIS-C hospitalizations through August 2021. One algorithm for the identification of cases in 2020 had a sensitivity of 82%, a low false positive rate of 22%, and a positive predictive value (PPV) of 78%. For hospitalizations in 2021, the sensitivity of the MIS-C diagnosis code was 98% with 84% PPV. CONCLUSION: We developed high-sensitivity algorithms to use for epidemiologic research and high-PPV algorithms for comparative effectiveness research. Accurate algorithms to identify MIS-C hospitalizations can facilitate important research for understanding this novel entity as it evolves during new waves.

Impact of the COVID-19 pandemic on hospitalizations of children with neurologic impairment.

INTRODUCTION: Children with neurologic impairment (NI) are frequently hospitalized for infectious and noninfectious illnesses. The early period of the COVID-19 pandemic was associated with overall lower pediatric hospitalization rates, particularly for respiratory infections, but the effect on utilization for children with NI is unknown. METHOD: This multicenter retrospective cohort study included hospitalizations of children 1-18 years of age with NI diagnosis codes from 49 children's hospitals. We calculated the percent change in the median weekly hospitalization volumes and the hospitalization resource intensity score (H-RISK), comparing the early-COVID era (March 15, 2020 to December 31, 2020) with the pre-COVID era (same timeframe of 2017-2019). Percent change was calculated over the entire study period as well as within three seasonal time periods (spring, summer, and fall/winter). Differences between infectious and noninfectious admission diagnoses were also examined. RESULTS: Compared with the pre-COVID era, there was a 14.4% decrease (interquartile range [IQR]: -33.8, -11.7) in the weekly median number of hospitalizations in the early-COVID era; the weekly median H-RISK score was 11.7% greater (IQR: 8.9, 14.9). Hospitalizations decreased for both noninfectious (-11.6%, IQR: -30.0, -8.0) and infectious (-35.5%, IQR: -51.1, -31.3) illnesses in the early-COVID era. This decrease was the largest in spring 2020 and continued throughout 2020. CONCLUSIONS: For children with NI, there was a substantial and significant decrease in hospitalizations for infectious and noninfectious diagnoses but an increase in illness severity during the early-COVID era compared with the pre-COVID era. Our data suggest a need to reconsider current thresholds for hospitalization and identify opportunities to support and guide families through certain illnesses without hospitalization.

Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial.

BACKGROUND: Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown. METHODS: The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16-19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16-19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems). DISCUSSION: The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05132322 . Registered on November 10, 2021.

How to Perform Quality Improvement Projects.

Safety and efficiency remain salient concerns for the US health-care system, especially in the face of growing health-care costs and morbidity from low-quality care. Current estimates suggest that more than 20% of health-care costs in the United States represent waste and low-value care, presenting numerous improvement opportunities. Although current guidelines and standards aim to address these problems, system processes and clinician behavior must also change to fill care gaps in the health-care system. Quality improvement (QI) is a systematic approach to safety or value gaps in care that uses data measured over time and then makes sequential, small changes to achieve a measurable aim. The Model for Improvement provides a general framework for approaching QI. In this review article, we describe the general approach to conducting QI studies in the health-care setting using the Model for Improvement as a guide, including identifying a problem, performing testing, measuring change, and implementing successful ideas. We also summarize common issues that QI teams face and should consider if sharing their QI work through publication. By following a systematic approach, QI teams can develop and implement interventions aimed at addressing gaps in care, thereby improving overall health-care value and safety for their patients.

Family Perspectives on Continuous Monitor Use in a Children's Hospital: A Qualitative Study.

OBJECTIVES: Alarms from continuous cardiorespiratory and pulse oximetry monitors may contribute to parental anxiety and poor sleep during hospitalization, yet families also may find monitoring reassuring. Our objective was to understand how families perceive the utility, benefits, and harms of continuous monitoring. METHODS: In this single-center qualitative study, we used semistructured interviews and direct observation. We enrolled families of patients of a variety of ages and clinical diagnoses. We extracted patient demographic information (age, diagnosis) from the health record. Semistructured interviews were recorded and transcribed. Detailed field notes were taken during observations. We used an inductive thematic approach to develop and refine codes that informed the development of themes. RESULTS: We recruited 24 families and conducted 23 interviews and 9 observation sessions. Respiratory conditions (eg, bronchiolitis, asthma) were the most common reason for hospitalization. The hospitalized children covered a range of ages: <4 weeks (16%), 4 weeks to 6 months (20%), 7 months to 5 years (44%), and >5 years (20%); 55% had previously been hospitalized. Families expressed varying degrees of understanding the utility of monitors and often conducted their own assessments before notifying staff about alarms. Families expected monitoring, including negative effects like sleep disruption, as part of hospitalization. Families perceived the benefit of monitoring in context of previous hospital experiences, often seeing less benefit and worrying less about alarms in subsequent hospitalizations. CONCLUSIONS: Family members continue to find reassurance from cardiorespiratory monitoring despite evidence that it offers limited benefit outside of the ICU setting. Parental perspectives should be addressed in future deimplementation efforts.

Improving Discharge Instructions for Hospitalized Children With Limited English Proficiency.

BACKGROUND AND OBJECTIVES: Patients with limited English proficiency (LEP) have increased risk of adverse events after hospitalization. At our institution, LEP families did not routinely receive translated discharge instructions in their preferred language. Our objective for this study was to increase the percentage of patients with LEP on the hospital medicine (HM) service receiving translated discharge instructions from 12% to 80%. METHODS: Following the Model for Improvement, we convened an interdisciplinary team that included HM providers, pediatric residents, language access services staff, and nurses to design and test interventions aimed at key drivers through multiple plan-do-study-act cycles. Interventions addressed the translation request process, care team education, standardizing discharge instructions for common conditions, and identification and mitigation of failures. We used established rules for analyzing statistical process control charts to evaluate the percentage of patients with translated discharge instructions for all languages and for Spanish. RESULTS: During the study period, 540 patients with LEP were discharged from the HM service. Spanish was the preferred language for 66% of patients with LEP. The percentage of patients with LEP who received translated discharge instructions increased from 12% to 50% in 3 months and to 77% in 18 months. For patients whose preferred language was Spanish, the percentage increased from 16% to 69% in 4 months and to 96% in 18 months. CONCLUSIONS: Interventions targeting knowledge of the translation process and standardized Spanish discharge instructions were associated with an increased percentage of families receiving translated discharge instructions. Future work will be used to assess the impact of these interventions on postdischarge disparities, including emergency department revisits and readmissions.

Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value.

OBJECTIVES: The health care system faces ongoing challenges due to low-value care. Building on the first pediatric hospital medicine contribution to the American Board of Internal Medicine Foundation Choosing Wisely Campaign, a working group was convened to identify additional priorities for improving health care value for hospitalized children. METHODS: A study team composed of nominees from national pediatric medical professional societies was convened, including pediatric hospitalists with expertise in clinical care, hospital leadership, and research. The study team surveyed national pediatric hospitalist LISTSERVs for suggestions, condensed similar responses, and performed a literature search of articles published in the previous 10 years. Using a modified Delphi process, the team completed a series of structured ratings of feasibility and validity and facilitated group discussion. The sum of final mean validity and feasibility scores was used to identify the 5 highest priority recommendations. RESULTS: Two hundred seven respondents suggested 397 preliminary recommendations, yielding 74 unique recommendations that underwent evidence review and rating. The 5 highest-scoring recommendations had a focus on the following aspects of hospital care: (1) length of intravenous antibiotic therapy before transition to oral antibiotics, (2) length of stay for febrile infants evaluated for serious bacterial infection, (3) phototherapy for neonatal hyperbilirubinemia, (4) antibiotic therapy for community-acquired pneumonia, and (5) initiation of intravenous antibiotics in infants with maternal risk factors for sepsis. CONCLUSIONS: We propose that pediatric hospitalists can use this list to prioritize quality improvement and scholarly work focused on improving the value and quality of patient care for hospitalized children.