Decreased Pseudomonas aeruginosa detection in children after separation of pediatric from adult cystic fibrosis clinics: A single center experience.

BACKGROUND: The impact of separating the adult from pediatric patients on Pseudomonas aeruginosa (P. aeriginosa) detection in the respiratory cultures of patients was examined at the University of Minnesota CF Center. METHODS: This study was a retrospective review using data recorded in the University of Minnesota CF Database between 1995 and 2010. Respiratory culture results obtained during routine University of Minnesota Cystic Fibrosis (CF) Center. CF clinic encounters of two cohorts of pediatric and adult CF patients (pre- and post-separation) were analyzed for presence of P. aeruginosa. RESULTS: The odds of a pediatric patient having P. aeruginosa were significantly less if the first culture was obtained after separation of pediatric and adult clinics. Being diagnosed by newborn screening or introduction of inhaled tobramycin did not affect this outcome. This reduction in P. aeruginosa was not detected in the adult cohort. CONCLUSIONS: Separation of pediatric and adult CF clinics has contributed to decrease in P. aeruginosa detection in pediatric patients.

The Use of a Triage-Based Protocol for Oral Rehydration in a Pediatric Emergency Department.

BACKGROUND: Guidelines recommend oral rehydration therapy (ORT) and avoidance of laboratory tests and intravenous fluids for mild to moderate dehydration in children with gastroenteritis; oral ondansetron has been shown to be an effective adjunct. OBJECTIVES: The aim of this study was to determine if a triage-based, nurse-initiated protocol for early provision of ondansetron and ORT could safely improve the care of pediatric emergency department (ED) patients with symptoms of gastroenteritis. METHODS: This study evaluated a protocol prompting triage nurses to assess dehydration in gastroenteritis patients and initiate ondansetron and ORT if indicated. Otherwise well patients aged 6 months to 5 years with symptoms of gastroenteritis were eligible. Prospective postintervention data were compared with retrospective, preintervention control subjects. RESULTS: One hundred twenty-eight (81 postintervention and 47 preintervention) patients were analyzed; average age was 2.1 years. Ondansetron use increased from 36% to 75% (P < 0.001). Time to ondansetron decreased from 60 minutes to 30 minutes (P = 0.004). Documented ORT increased from 51% to 100% (P < 0.001). Blood testing decreased from 37% to 21% (P = 0.007); intravenous fluid decreased from 23% to 9% (P = 0.03). Fifty-two percent of postintervention patients were discharged with prescriptions for ondansetron. There were no significant changes in ED length of stay, admissions, or unscheduled return to care. CONCLUSIONS: A triage nurse-initiated protocol for early use of oral ondansetron and ORT in children with evidence of gastroenteritis is associated with increased and earlier use of ondansetron and ORT and decreased use of IV fluids and blood testing without lengthening ED stays or increasing rates of admission or unscheduled return to care.

Implementation of an Electronic Clinical Decision Support Tool for Pediatric Appendicitis Within a Hospital Network.

OBJECTIVES: Computed tomography (CT) has been widely used in the evaluation of children with suspected appendicitis, but concerns about ionizing radiation have increased interest in ultrasound for these patients. We sought to assess the effectiveness of an appendicitis electronic clinical decision support (E-CDS) system in increasing ultrasound and decreasing CT use in children evaluated in emergency departments (EDs) for suspected appendicitis. METHODS: This was a preintervention and postintervention analysis of an E-CDS implemented into an electronic health record system shared by an academic, tertiary-care children's hospital and a community hospital. The tool consisted of a structured order set with embedded clinical advice and a link to a Web site. Emergency department patients aged 3 to 18 years with suspected appendicitis were reviewed retrospectively. Imaging use was assessed 3 months before and 6 months after implementation of the intervention. RESULTS: Three hundred twenty-seven patients were identified, 211 at postintervention; 80% were seen in the community ED. Among community ED patients with imaging, ultrasound use increased (36%-51%, P = 0.049), and CT scan use decreased (81%-66%, P = 0.044) in the postintervention period, with no change in complications or safety outcomes. No difference was found in ultrasound rate (100%-97%, P = 1.000) or CT scan rate (13%-10%, P = 1.000) among children's ED patients with imaging. CONCLUSIONS: An E-CDS can effectively decrease CT scanning and increase use of ultrasound in children with suspected appendicitis in a community hospital ED. Electronic clinical decision support may be an effective method of disseminating pediatric best practices from a children's hospital to affiliated community EDs.

Objective Measurement of Adherence to Out-Patient Airway Clearance Therapy by High-Frequency Chest Wall Compression in Cystic Fibrosis.

BACKGROUND: Objective measures of adherence to high-frequency chest wall compression (HFCWC), a form of airway clearance therapy for patients with cystic fibrosis, are lacking. We used a novel electronic monitoring device integrated into an HFCWC vest to measure adherence compared with self-reported adherence. We determined factors that influenced adherence and how adherence correlated with baseline pulmonary function and pulmonary exacerbations. METHODS: Data were collected by direct measurement of date, time of day, and duration of HFCWC use to determine the number of daily treatments and daily duration of treatments. Chart review provided prescribed airway clearance therapy treatment and demographic and clinical information. Subject and caregiver report of the daily number of airway clearance therapy treatments was obtained by telephone interviews. Analysis used 2-sample and paired t test, analysis of variance, and linear regression. RESULTS: Average adherence was 69%. Adherence was highest in children (82%, P = .02) and those receiving assistance with treatment (82%, P < .001). Subjects overestimated therapy duration from a mean ± SD of 127 ± 169% by adults to 19.2 ± 26.3% by parents or guardians of children. Average adherence decreased with increasing prescribed therapy time (P = .02). Average daily therapy time and adherence had significant positive associations with baseline FEV1 percent of predicted (P = .02 and P = .02, respectively) and negative associations with pulmonary exacerbations during the pre-study period and at baseline (P = .044 and P = .02, respectively). CONCLUSIONS: Greater adherence to HFCWC measured directly by a novel recorder was associated with better baseline pulmonary function and fewer exacerbations in the pre-study and baseline period. Adherence decreased with age and prescribed therapy time and increased with therapy assistance. Self-report overestimation is large and thus not an accurate measure of adherence.

Community Primary Care Provider Preferences for Emergency Department Follow-up Recommendations: A Regional Study.

BACKGROUND: Children who present to emergency departments (EDs) for care are frequently advised to follow up with their primary care providers (PCPs) after discharge; little is known about whether PCPs agree that follow-up advised by EDs is appropriate for their patients. OBJECTIVES: The aims of this study were to determine PCP preferences for follow-up recommendations given to their pediatric patients at the time of ED visits and to compare these preferences to reported emergency medicine provider (EMP) practice. METHODS: This was an online survey of PCPs and EMPs in a regional health system assessing preferred timing for ED follow-up recommendations for 15 common pediatric conditions and whether the follow-up should be definite or contingent. RESULTS: Ninety PCPs and 36 EMPs responded to the survey. In patients with community-acquired pneumonia, probability of recommending follow-up after 5 or more days was 33% in PCPs and 8% in EMPs (P = 0.001). In all conditions with significant differences, PCPs favored longer follow-up. In upper respiratory tract infection and acute otitis media, PCPs had a higher probability than EMPs of selecting as-needed versus definite follow-up (P = 0.0002 and P = 0.01, respectively). In asthma, concussion, and pneumonia, PCPs had a significantly lower probability of selecting as-needed follow-up than EMPs. CONCLUSIONS: In this regional survey, PCPs preferred longer times between ED visit and follow-up than EMPs for a number of conditions. Differences were also found in preference for as-needed or definite follow-up, varying by condition. These discrepancies could result in overuse or underuse of clinic resources, suggesting a possible quality improvement target for emergency medicine practice.

Babesia microti seroprevalence in Minnesota blood donors.

BACKGROUND: The increasing frequency of transfusion-transmitted babesiosis represents a concern for the safety of the US blood supply. The agent responsible for the disease, the intraerythrocytic parasite Babesia microti, is naturally transmitted to humans by a tick bite and is endemic in areas of the Northeast and Upper Midwest United States. In this study, we explored B. microti seroprevalence in blood donors from different areas of Minnesota (MN). STUDY DESIGN AND METHODS: We tested 2150 blood donors in MN for the presence of antibodies against B. microti using an immunofluorescent assay (IFA). Donors identified as positive (≥64) were also tested by real-time polymerase chain reaction (PCR) for the presence of parasite DNA. Seropositive donors were contacted by phone and asked questions regarding tick exposure. Donors positive by IFA were indefinitely deferred from donating blood. RESULTS: A total of 2150 donations were tested between October 2010 and November 2011. Forty-two donors (2.0%) were positive by IFA and one was also PCR positive. All positive donors reported extended outdoor activities, 12 recalled finding ticks on their body, and six had flu-like symptoms since their last blood draw. CONCLUSIONS: This study provides new data about B. microti seroprevalence in MN blood donors. Possibly because the targeted collection areas were mostly expected to be endemic for the parasite, the observed seroprevalence levels were higher than expected, although the geographic distribution of positive donors did not completely overlap with the distribution of reported clinical cases in MN.