Hierarchy of Evidence Within the Medical Literature.

The quality of evidence from medical research is partially deemed by the hierarchy of study designs. On the lowest level, the hierarchy of study designs begins with animal and translational studies and expert opinion, and then ascends to descriptive case reports or case series, followed by analytic observational designs such as cohort studies, then randomized controlled trials, and finally systematic reviews and meta-analyses as the highest quality evidence. This hierarchy of evidence in the medical literature is a foundational concept for pediatric hospitalists, given its relevance to key steps of evidence-based practice, including efficient literature searches and prioritization of the highest-quality designs for critical appraisal, to address clinical questions. Consideration of the hierarchy of evidence can also aid researchers in designing new studies by helping them determine the next level of evidence needed to improve upon the quality of currently available evidence. Although the concept of the hierarchy of evidence should be taken into consideration for clinical and research purposes, it is important to put this into context of individual study limitations through meticulous critical appraisal of individual articles.

Improving Efficiency of Pediatric Hospital Medicine Team Daily Workflow.

BACKGROUND AND OBJECTIVES: Workflow inefficiencies by medical teams caring for hospitalized patients may affect patient care and team experience. At our institution, complexity and clinical volume of the pediatric hospital medicine (HM) service have increased over time; however, efficient workflow expectations were lacking. We aimed to increase the percentage of HM teams meeting 3 efficiency criteria (70% nurses present for rounds, rounds completed by 11:30 am, and HM attending notes completed by 5 pm) from 28% to 80% within 1 year. METHODS: Improvement efforts targeted 5 HM teams at a large academic hospital. Our multidisciplinary team, including HM attending physicians, pediatric residents, and nurses, focused on several key drivers: shared expectations, enhanced physician and nursing buy-in and communication, streamlined rounding process, and data transparency. Interventions included (1) daily rounding expectations with prerounds huddle, (2) visible reminders, (3) complex care team scheduled rounds, (4) real-time nurse notification of rounds via electronic platform, (5) workflow redesign, (6) attending feedback and data transparency, and (7) resource attending implementation. Attending physicians entered efficiency data each day through a Research Electronic Data Capture survey. Annotated control charts were used to assess the impact of interventions over time. RESULTS: Through sequential interventions, the percentage of HM teams meeting all 3 efficiency criteria increased from 28% to 61%. Nursing presence on rounds improved, and rounds end time compliance remained high, whereas attending note completion time remained variable. CONCLUSIONS: Inpatient workflow for pediatric providers was improved by setting clear expectations and enhancing team communication; competing demands while on service contributed to difficulty in improving timely attending note completion.

Clinical Guideline Highlights for the Hospitalist: Maintenance Intravenous Fluids in Infants and Children.

GUIDELINE TITLE: 2018 American Academy of Pediatrics (AAP) Clinical Practice Guideline: Maintenance Intravenous Fluids in Children RELEASE DATE: November 26, 2018 PRIOR VERSION: Not Applicable DEVELOPER: Multidisciplinary subcommittee of experts assembled by the AAP FUNDING SOURCE: AAP TARGET POPULATION: Patients 28 days to 18 years of age requiring maintenance intravenous fluids (IVFs).

Implementation of a Communication Bundle for High-Risk Patients.

BACKGROUND: Interventions that facilitate early identification and management of hospitalized pediatric patients who are at risk for deterioration are associated with decreased mortality. In our large pediatric hospital with a history of success in decreasing unrecognized deterioration, patients at higher risk of deterioration are termed "watchers." Because communication errors often contribute to unrecognized deterioration, clear and timely communication of watcher status to all team members and contingency planning was desired. OBJECTIVES: Increase the percentage of eligible watchers with a complete communication, teamwork, and planning bundle within 2 hours of identification from 28% to 80%. METHODS: Watchers admitted to Hospital Medicine on 2 targeted units were eligible. Stakeholders were educated to facilitate ownership. Daily data analysis enabled real-time failure identification. Automated physician notification provided reminders for timely communication. RESULTS: The percentage of watchers with a complete situation awareness bundle within 2 hours increased from 28% to 81% and was sustained for more than 2 years. There was no change in rates of rapid response team calls or ICU transfers on our intervention units, but these both increased throughout the hospital. Education facilitated modest improvement, with marked improvements and sustainment through use of technology. CONCLUSIONS: A novel bundle that included contingency planning and communication expectations was created to improve situation awareness for watchers. Multidisciplinary engagement and use of automated technology facilitated by an electronic health record helped implement and sustain bundle adherence.

Computed Tomography and Shifts to Alternate Imaging Modalities in Hospitalized Children.

BACKGROUND: Many studies have demonstrated a rise in computed tomography (CT) utilization in abstract children's hospitals. However, CT utilization may be declining, perhaps due to awareness of potential hazards of pediatric ionizing radiation, such as increased risk of malignancy. Th e objective is to assess the trend in CT utilization in hospitalized children at freestanding children's hospitals from 2004 to 2012 and we hypothesize decreases are associated with shifts to alternate imaging modalities. METHODS: Multicenter cross-sectional study of children admitted to 33 pediatric tertiary-care hospitals participating in the Pediatric Health Information System between January 1, 2004, and December 31, 2012. The rates of CT, ultrasound, and MRI for the top 10 All-Patient Refined Diagnosis Related Groups (APR-DRGs) for which CT was performed in 2004 were determined by billing data. Rates of each imaging modality for those top 10 APR-DRGs were followed through the study period. Odds ratios of imaging were adjusted for demographics and illness severity. RESULTS: For all included APR-DRGs except ventricular shunt procedures and nonbacterial gastroenteritis, the number of children imaged with any modality increased. CT utilization decreased for all APR-DRGs (P values , .001). For each of the APR-DRGs except seizure and infections of upper respiratory tract, the decrease in CT was associated with a significant rise in an alternative imaging modality (P values # .005). CONCLUSIONS: For the 10 most common APR-DRGs for which children received CT in 2004,a decrease in CT utilization was found in 2012. Alternative imaging modalities for 8 of the diagnoses were used.

Suctioning and length of stay in infants hospitalized with bronchiolitis.

IMPORTANCE: Hospitalizations of infants for bronchiolitis are common and costly. Despite the high incidence and resource burden of bronchiolitis, the mainstay of treatment remains supportive care, which frequently includes nasal suctioning. OBJECTIVE: To examine the association between suctioning device type and suctioning lapses greater than 4 hours within the first 24 hours after hospital admission on length of stay (LOS) in infants with bronchiolitis. DESIGN: Retrospective cohort study. Data were extracted from the electronic health record. SETTING: Main hospital and satellite facility of a large quaternary care children's hospital from January 10, 2010, through April 30, 2011. PARTICIPANTS: A total of 740 infants aged 2 to 12 months and hospitalized with bronchiolitis. MAIN OUTCOME MEASURE: Hospital LOS. RESULTS: In the multivariable model adjusted for inverse weighting for propensity to receive deep suctioning, increased deep suction as a percentage of suction events was associated with increased LOS with a geometric mean of 1.75 days (95% CI, 1.56-1.95 days) in patients with no deep suction and 2.35 days (2.10-2.62 days) in patients with more than 60% deep suction. An increased number of suctioning lapses was also associated with increased LOS in a dose-dependent manner with a geometric mean of 1.62 days (95% CI, 1.43-1.83 days) in patients with no lapses and 2.64 days (2.30-3.04 days) in patients with 3 or 4 lapses. CONCLUSIONS AND RELEVANCE: For patients admitted with bronchiolitis, the use of deep suctioning in the first 24 hours after admission and lapses greater than 4 hours between suctioning events were associated with longer LOS.

Rapid adoption of Lactobacillus rhamnosus GG for acute gastroenteritis.

BACKGROUND AND OBJECTIVES: A 2007 meta-analysis showed probiotics, specifically Lactobacillus rhamnosus GG (LGG), shorten diarrhea from acute gastroenteritis (AGE) by 24 hours and decrease risk of progression beyond 7 days. In 2005, our institution published a guideline recommending consideration of probiotics for patients with AGE, but only 1% of inpatients with AGE were prescribed LGG. The objective of this study was to increase inpatient prescribing of LGG at admission to >90%, for children hospitalized with AGE, within 120 days. METHODS: This quality improvement study included patients aged 2 months to 18 years admitted to general pediatrics with AGE with diarrhea. Diarrhea was defined as looser or ≥ 3 stools in the preceding 24 hours. Patients with complex medical conditions or with presumed bacterial gastroenteritis were excluded. Admitting and supervising clinicians were educated on the evidence. We ensured LGG was adequately stocked in our pharmacies and updated an AGE-specific computerized order set to include a default LGG order. Failure identification and mitigation were conducted via daily electronic chart review and e-mail communication. Primary outcome was the percentage of included patients prescribed LGG within 18 hours of admission. Intervention impact was assessed with run charts tracking our primary outcome over time. RESULTS: The prescribing rate increased to 100% within 6 weeks and has been sustained for 7 months. CONCLUSIONS: Keys to success were pharmacy collaboration, use of an electronic medical record for a standardized order set, and rapid identification and mitigation of failures. Rapid implementation of evidence-based practices is possible using improvement science methods.