An Interprofessional Initiative to Address Tests Pending at Discharge for Hospitalized Pediatric Patients.

INTRODUCTION: Pediatric hospitalized patients often are discharged before all lab tests are completed. Given the risk of medical errors related to inadequate test follow-up, we piloted a collaborative initiative to address tests pending at discharge (TPAD) within our pediatric hospital medicine section. Our objectives were to delineate the responsibilities of case managers and pediatric hospital medicine clinicians in addressing these tests and to establish a communication process. METHODS: We formed an interprofessional team and performed a current state assessment, including a survey to pediatric hospital medicine clinicians to assess time spent following up TPAD and confidence that results were followed up in a timely and appropriate manner. We obtained a list of 1450 individual TPAD for the previous 9 months using an electronic health record data query, from which a list of 26 common and straightforward labs were identified for case manager follow-up. A shared case manager Epic Inbasket for TPAD was created and was checked twice daily. We developed a phased approach to establish a workflow for follow-up. DISCUSSION: The case manager partnership was launched in 4 phases for the duration of the 6-month pilot. However, due to duplication of work and less value of case managers addressing straightforward labs, the pilot was stopped. A more effective and mutually beneficial role for pediatric hospital medicine attendings and case managers may be to have the case managers address complex TPAD and communicate with primary care clinicians and families.

Use of Clinical Practice Guideline to Improve Management of Osteoarticular Infections in Children.

OBJECTIVES: Osteoarticular infections (OAIs) in children pose significant risks if incorrectly managed. We introduced a clinical practice guideline (CPG) to decrease use of broad-spectrum and intravenous (IV) antibiotics for OAI treatment. The primary aims of our project were to decrease the percent of patients with empirical broad cephalosporin use to 10% and decrease IV antibiotic therapy on discharge to 20% while increasing narrow-spectrum oral antibiotic use to 80% within 24 months. METHODS: We used quality improvement methodology to study patients diagnosed with OAIs. Interventions included multidisciplinary workgroup planning, CPG implementation, education, information technology, and stakeholder feedback. Outcome measures were the percentage of patients prescribed empirical broad-spectrum cephalosporins, percent discharged on IV antibiotics, and percent discharged on narrow-spectrum oral antibiotics. Process measures included percent of patients hospitalized on medicine service and infectious diseases consultation. Balancing measures included rates of adverse drug reactions, disease complications, length of stay, and readmission within 90 days. The impact of the interventions was assessed with run and control charts. RESULTS: A total of 330 patients were included over 96 months. The percentage of patients with empirical broad cephalosporin coverage decreased from 47% to 10%, percent discharged on IV antibiotics decreased from 75% to 11%, and percent discharged on narrow-spectrum oral antibiotics increased from 24% to 84%. Adverse drug reactions decreased from 31% to 10%. Rates of complications, readmissions, and length of stay were unchanged. CONCLUSIONS: Through development and implementation of a CPG for OAI management, we demonstrated decreased use of empirical broad-spectrum antibiotics and improved definitive antibiotic management.

A novel faculty development tool for writing a letter of recommendation.

OBJECTIVE: Based on a national survey of program directors we developed a letter of recommendation (LOR) scoring rubric (SR) to assess LORs submitted to a pediatric residency program. The objective was to use the SR to analyze: the consistency of LOR ratings across raters and LOR components that contributed to impression of the LOR and candidate. METHODS: We graded 30 LORs submitted to a pediatric residency program that were evenly distributed based on final rank by our program. The SR contained 3 sections (letter features, phrases, and applicant abilities) and 2 questions about the quality of the LOR (LORQ) and impression of the candidate (IC) after reading the LOR on a 5-point Likert scale. Inter-rater reliability was calculated with intraclass correlation coefficients (ICC(2,1)). Pearson (r) correlations and stepwise multivariate linear regression modeling predicted LORQ and IC. Mean scores of phrases, features, and applicant abilities were analyzed with ANOVA and Bonferroni correction. RESULTS: Phrases (ICC(2,1) = 0.82, p<0.001)) and features (ICC(2,1) = 0.60, p<0.001)) were rated consistently, while applicant abilities were not (ICC(2,1) = 0.28, p<0.001)). For features, LORQ (R2 = 0.75, p<0.001) and IC (R2 = 0.58, p<0.001) were best predicated by: writing about candidates' abilities, strength of recommendation, and depth of interaction with the applicant. For abilities, LORQ (R2 = 0.47, p<0.001) and IC (R2 = 0.51, p<0.001) were best predicted by: clinical reasoning, leadership, and communication skills (0.2). There were significant differences for phrases and features (p<0.05). CONCLUSIONS: The SR was consistent across raters and correlates with impression of LORQ and IC. This rubric has potential as a faculty development tool for writing LORS.