Nine Seasons of a Bronchiolitis Observation Unit and Home Oxygen Therapy Protocol.

BACKGROUND: We implemented an observation unit and home oxygen therapy (OU-HOT) protocol at our children's hospital during the 2010-2011 winter season to facilitate earlier discharge of children hospitalized with bronchiolitis. An earlier study demonstrated substantial reductions in inpatient length of stay and costs in the first year after implementation. OBJECTIVE: Evaluate long-term reductions in length of stay and cost. DESIGN, SETTING, AND PARTICIPANTS: Interrupted time-series analysis, adjusting for patient demographic factors and disease severity. Participants were children aged 3 to 24 months and hospitalized with bronchiolitis from 2007 to 2019. INTERVENTION: OU-HOT protocol implementation. MAIN OUTCOME AND MEASURES: Hospital length of stay. Process measures were the percentage of patients discharged from the OU; percentage of patients discharged with HOT. Balancing measures were 7-day hospital revisit rates; annual per-population bronchiolitis admission rates. Secondary outcomes were inflation-adjusted cost per episode of care and discharges within 24 hours. RESULTS: A total of 7,116 patients met inclusion criteria. The OU-HOT protocol was associated with immediate decreases in mean length of stay (-30.6 hours; 95% CI, -37.1 to -24.2 hours) and mean cost per episode of care (-$4,181; 95% CI, -$4,829 to -$3,533). These findings were sustained for 9 years after implementation. Hospital revisit rates did not increase immediately (-1.1% immediate change; 95% CI, -1.8% to -0.4%), but a small increase in revisits was observed over time (change in slope 0.4% per season, 95% CI, 0.1%-0.8%). CONCLUSION: The OU-HOT protocol was associated with sustained reductions in length of stay and cost, representing a promising strategy to reduce the inpatient burden of bronchiolitis.

A systematic review of predictive modeling for bronchiolitis.

PURPOSE: Bronchiolitis is the most common cause of illness leading to hospitalization in young children. At present, many bronchiolitis management decisions are made subjectively, leading to significant practice variation among hospitals and physicians caring for children with bronchiolitis. To standardize care for bronchiolitis, researchers have proposed various models to predict the disease course to help determine a proper management plan. This paper reviews the existing state of the art of predictive modeling for bronchiolitis. Predictive modeling for respiratory syncytial virus (RSV) infection is covered whenever appropriate, as RSV accounts for about 70% of bronchiolitis cases. METHODS: A systematic review was conducted through a PubMed search up to April 25, 2014. The literature on predictive modeling for bronchiolitis was retrieved using a comprehensive search query, which was developed through an iterative process. Search results were limited to human subjects, the English language, and children (birth to 18 years). RESULTS: The literature search returned 2312 references in total. After manual review, 168 of these references were determined to be relevant and are discussed in this paper. We identify several limitations and open problems in predictive modeling for bronchiolitis, and provide some preliminary thoughts on how to address them, with the hope to stimulate future research in this domain. CONCLUSIONS: Many problems remain open in predictive modeling for bronchiolitis. Future studies will need to address them to achieve optimal predictive models.

Decreasing hospital length of stay for bronchiolitis by using an observation unit and home oxygen therapy.

IMPORTANCE: Pediatric observation units (OUs) offer the opportunity to safely and efficiently care for common illnesses previously cared for in an inpatient setting. Home oxygen therapy (HOT) has been used to facilitate hospital discharge in patients with hypoxic bronchiolitis. It is unknown how implementation of a hospitalwide bronchiolitis treatment protocol promoting OU-HOT would affect hospital length of stay (LOS). OBJECTIVE: To test the hypothesis that using OU-HOT for bronchiolitis would decrease LOS. DESIGN AND SETTING: Retrospective cohort study at Primary Children's Medical Center, Salt Lake City, Utah. PARTICIPANTS: Uncomplicated bronchiolitis patients younger than 2 years admitted during the winter seasons of 2005 through 2011. INTERVENTIONS: Implementation of a new bronchiolitis care process encouraging use of an OU-HOT protocol. MAIN OUTCOME MEASURES: Mean hospital LOS, discharge within 24 hours, emergency department (ED) bronchiolitis admission rates and ED revisit/readmission rates, and inflation-adjusted cost. RESULTS: A total of 692 patients with bronchiolitis from the 2010-2011 bronchiolitis season were compared with 725 patients from the 2009-2010 season. Implementation of an OU-HOT protocol was associated with a 22.1% decrease in mean LOS (63.3 hours vs 49.3 hours, P < .001). Although LOS decreased during all 6 winter seasons, linear regression and linear quantile regression analyses for the 2005-2011 LOS data demonstrated a significant acceleration in the LOS decrease for the 2010-2011 season after implementation of the OU-HOT protocol. Discharges within 24 hours increased from 20.0% to 38.4% (P < .001), with no difference in ED bronchiolitis admission or ED revisit/readmission rates. After implementation of the OU-HOT protocol, the total cost per admitted case decreased by 25.4% ($4800 vs $3582, P < .001). CONCLUSIONS AND RELEVANCE: Implementation of an OU-HOT protocol for patients with bronchiolitis safely reduces hospital LOS with significant cost savings. Although widespread implementation has the potential for dramatic cost savings nationally, further studies assessing overall health care use and cost, including the impact on families and outpatient practices, are needed.

Clinical reasoning: a 12-year-old boy with ascending weakness.

A 12-year-old boy presented with 3 weeks of calf pain, tripping, and progressive inability to walk. The onset was preceded by a sore throat 4 weeks prior, but no recent immunizations and no sick contacts. He began having problems "catching his toes" for 2 weeks. He had no visual complaints and no bowel or bladder incontinence. He had no recent travel and there were no heavy metal or solvent exposures. He had no prior medical history and he was on no prescription medications. Developmentally, he was on track and had just successfully completed fifth grade. However, he was reported to be behaviorally oppositional, especially regarding his diet which was restricted to beef jerky, yogurt from a squeeze tube, and fruit drinks. Family history included diabetic peripheral neuropathy in his mother, idiopathic peripheral neuropathy in his maternal grandfather, and left lower extremity neuropathy from trauma in his father. There was no known family history of recurrent pressure palsies or cardiac problems.

Clinical and economic outcomes for term infants associated with increasing administration of antibiotics to their mothers.

Implementation of national guidelines for the prevention of group B streptococcal (GBS) infections has led to an increase in intrapartum antibiotic use and reduction in early-onset GBS infections in newborns. Other outcomes, including the clinical diagnosis of sepsis in term infants, treatment with antibiotics, length of stay, and cost have not been described. To examine these outcomes, we performed an analysis of maternal and newborn data collected between 1998 and 2002 of 130 447 in-hospital births of newborns >or=37 weeks gestation and their mothers from a large vertically integrated healthcare organisation in Utah. The main outcome measures included: (i) the number of women delivering at term who received intravenous antibiotics; (ii) the number of newborns treated for 'clinical sepsis', which was defined as receiving antibiotics for >72 h and the number of newborns who received antibiotics for

Mortality of late-preterm (near-term) newborns in Utah.

OBJECTIVES: The purpose of this work was to determine the relative risk for mortality and the causes and ages of death for late-preterm newborns (gestational age of 34-36 weeks) compared with those born at term. METHODS: We reviewed data from birth and death certificates of infants born in Utah between 1999 and 2004. We calculated early neonatal (first week), neonatal (first 28 days), and infant (first year) mortality rates for each weekly estimated gestational age cohort from 34 to 42 weeks and, using 40 weeks as the reference, risk ratios for each cohort. Causes of death were grouped into 8 categories and compared for near term and term newborns. Crude mortality rates and risk ratios for death from all causes and for infants dying of all causes other than birth defects were measured. RESULTS: Birth defects were the single-most common cause of death for both term and late-preterm newborns. Mortality rates for late-preterm newborns remained significantly higher after excluding those who died of birth defects from the comparisons. CONCLUSIONS: Compared with those born at term, late-preterm (near-term) newborns have significantly higher mortality rates. Each weekly increase in estimated gestational age is associated with a decreasing risk of death. Birth defects are the leading cause of death among late-preterm newborns but do not entirely account for their higher risk of death.

Deformational plagiocephaly: development of an objective measure and determination of its prevalence in primary care.

Referrals for deformational plagiocephaly (DP) have increased, but estimates of its actual prevalence vary, depending on the population studied and criteria for diagnosis. Few studies employ an objective technique for diagnosis. The objectives of this study were to validate the Transcranial Diameter Difference (TDD) and, using it, determine the prevalence of DP among infants seen by primary care pediatricians. We determined the TDD of 32 infants referred to a craniofacial clinic for DP; blinded to the TDD a craniofacial surgeon assigned a DP severity score. We compared the TDD and severity scores. The TDD of 192 infants presenting to primary care practices (PCP) were determined and their parents completed a DP risk factor questionnaire. Odds ratios for associations of risk factors with DP were calculated. The correlation between TDD and DP severity score was 0.61 (P = 0.002). All infants whose TDD > 0.6 cm had a severity score > 2; 18.2% of the 192 infants had DP as defined by a TDD > 0.6 cm. Significant odds ratios (95% confidence intervals) for the presence of DP were sleeping supine, 3.5; (1.6, 7.5), and infant head position preference 2.2; (1.0, 4.9). Varying the sleep position decreased the risk of DP, OR = 0.40 (0.2, 0.9). We conclude that the TDD is a valid, objective measure of DP for use in research studies. DP is present in nearly one in five PCP infants. Because an infant who prefers to hold his head in one position is more likely to have DP, advising parents to vary the head position may reduce the risk of DP.

Association of intrapartum antibiotic exposure and late-onset serious bacterial infections in infants.

OBJECTIVE: Recommendations to prevent vertical transmission of group B Streptococcus (GBS) infections have resulted in many women's receiving antibiotics during labor with an associated reduction in early-onset GBS infections in their newborn infants. However, a potential relationship of intrapartum antibiotics (IPA) to the occurrence of late-onset (7-90 days) serious bacterial infections (SBIs) in term infants has not been reported. The objectives of this study were to determine whether infants with late-onset SBI were more likely than healthy control infants to have been exposed to IPA and whether there was a greater likelihood of antibiotic resistance in bacteria that were isolated from infants who had an SBI and had been exposed to IPA compared with those who had not. METHODS: We used a case-control design to study the first objective. Cases were previously healthy full-term infants who were hospitalized for late-onset SBI between the ages of 7 and 90 days. Control subjects were healthy full-term infants who were known not to have an SBI in their first 90 days. Cases and control subjects were matched for hospital of delivery. In the second part of the study, rates of antibiotic resistance of bacteria that were isolated from infected infants were compared for those who had and had not been exposed to IPA. RESULTS: Ninety case infants and 92 control subjects were studied. Considering all types of IPA, more case (41%) than control infants (27%) had been exposed to IPA (adjusted odds ratio [OR]: 1.96; 95% confidence interval [CI]: 1.05-3.66), after controlling for hospital of delivery. The association was stronger when IPA was with broad-spectrum antibiotics (adjusted OR: 4.95; 95% CI: 2.04-11.98), after controlling for hospital of delivery, penicillin IPA, maternal chorioamnionitis, and breastfeeding. Bacteria that were isolated from infected infants who had been exposed to IPA were more likely to exhibit ampicillin resistance (adjusted OR: 5.7; 95% CI: 2.3-14.3), after controlling for hospital of delivery, but not to other antibiotics that are commonly used to treat SBI in infants. CONCLUSIONS: After adjusting for potential confounders, infants with late-onset SBI were more likely to have been exposed to IPA than noninfected control infants. Pathogens that cause late-onset SBI were more likely to be resistant to ampicillin when the infant had been exposed to intrapartum antibiotics.

Serious bacterial infections in febrile infants younger than 90 days of age: the importance of ampicillin-resistant pathogens.

BACKGROUND: Intrapartum antibiotic prophylaxis against group B Streptococcus (GBS) has reduced the occurrence of serious bacterial infections (SBI) in young infants caused by GBS. Recommendations for initial antibiotic therapy for the febrile infant 1 to 90 days old were developed when infections with GBS were common and antibiotic resistance was rare. OBJECTIVE: To document the pathogens responsible for SBI in recent years in febrile infants 1 to 90 days old and the antibiotic susceptibility of these organisms. METHODS: The results of bacterial cultures from infants 1 to 90 days old evaluated for fever at Primary Children's Medical Center in Salt Lake City, Utah, between July 1999 and April 2002 were analyzed. Antibiotic susceptibility profiles were collected and patient records were reviewed to determine if initial antibiotic therapy was changed following the identification of the organism. RESULTS: Of 1298 febrile infants enrolled from the Primary Children's Medical Center emergency department, 105 (8%) had SBI. The mean age of the infants with SBI was 39 days (range 2-82 days) and 2 (2%) were <7 days. SBI included urinary tract infection (UTI; 67%), bacteremia (16%), bacteremia and UTI (6%), bacteremia and meningitis (5%), meningitis (2%), abscess (2%), meningitis and UTI (1%), and meningitis and gastroenteritis (1%). Eighty-three (79%) of 105 episodes of SBI were caused by Gram-negative bacteria, including 92% of UTI, 54% of bacteremia, and 44% of meningitis cases. The most common pathogen was Escherichia coli (61%). Other Gram-negative pathogens were responsible for 19% of SBI. Staphylococcus aureus was the most common Gram-positive pathogen, causing 8% of SBI. GBS accounted for 6% of SBI. Of the 105 pathogens, 56 (53%) were resistant to ampicillin. Of the pathogens causing meningitis, UTI, and bacteremia, 78%, 53%, and 50%, respectively, were resistant to ampicillin. Antibiotic therapy was changed in 54% of cases of SBI following identification of the organism. CONCLUSIONS: In Utah, ampicillin-resistant Gram-negative bacteria are the most common cause of SBI in febrile infants <90 days old. This finding impacts antibiotic selection, especially in cases of meningitis. Local surveillance of pathogens and antibiotic susceptibility patterns is critical to determine appropriate antibiotic therapy.