Improving inpatient cystic fibrosis pulmonary exacerbation care: two success stories.

BACKGROUND: Pulmonary exacerbations (PEx) in cystic fibrosis (CF) are a frequent cause of hospitalisations and lead to long-term decline in pulmonary function. Successful CF inpatient care requires the coordination of multiple providers and complex therapies. Children's Hospital of Wisconsin (CHW) and Children's Healthcare of Atlanta (CHoA) independently identified PEx inpatient care for focused improvements, with emphasis on improving care coordination and patient outcomes. METHODS: Both centres began by forming multidisciplinary workgroups, including patient and family representatives. CHW's specific aim was to eliminate delays in the time to initial intravenous antibiotics. A written handoff tool was developed to allow more efficient ordering. Efforts at CHoA focused on coordination and consistent care delivery. A written schedule and patient incentive programme were devised to ensure proper administration of treatments and promote patient adherence. RESULTS: At CHW, interventions decreased the mean antibiotic order time by 59% with resultant decrease in administration time by 25%. At CHoA, improvements led to a 42% decrease in the proportion of hospitalisations unsuccessful in returning lung function back to within 90% of baseline. CONCLUSIONS: Inpatient CF PEx care is complex and requires multiple competing activities and treatments. Consistent and timely delivery of these treatments is challenging. Our improvements used the skills and insights of providers and patients to improve, standardise and synchronise care, and to develop tools to coordinate hand offs. With these improvements, applicable to hospital treatment of many other conditions, both centres were successfully able to deliver treatments in a more consistent and timely manner with improved outcomes.

Chiari I malformation presenting as chronic cough.

We present a 9-month-old infant with persistent cough refractory to conventional asthma therapy. An extensive evaluation eventually revealed a Chiari I malformation with syringohydromyelia. His cough resolved one month after surgical decompression, suggesting that brainstem compression from the Chiari malformation directly caused his symptoms.

Decreased prevalence of asthma among farm-reared children compared with those who are rural but not farm-reared.

BACKGROUND: Farm exposure has been associated with decreased asthma prevalence. OBJECTIVES: We compared asthma prevalence among rural farm-reared and non-farm-reared children and examined farm demographic and environmental factors. METHODS: We performed a cross-sectional, population-based survey among 36,500 rural kindergarten through 12th grade school children. Surveys were distributed through schools and returned by mail. RESULTS: Of the 4152 participants, 18% had lived or were currently living on a farm. Compared to other rural children, farm children had more siblings (3.0 vs 2.5; P < .015), were more likely to be breast-fed (64% vs 58%; P < .002), to have pets (88% vs 79%; P < .001), and were less likely to have attended daycare (39% vs 50%; P < .001). Farm-reared children were less likely to have had a history of wheezing (28% vs 34%; P < .003) or a diagnosis of asthma (22% vs 26%; P < .002). This effect was greater among children younger than 10 years of age than among older children. There was no difference in the frequency of either asthma or non-asthma allergy symptoms during the previous 12 months. When analyzed by age and sex, decreased asthma prevalence was associated with farm rearing among younger children more than among adolescents. Farm residence beginning during the first 5 years, but not later, was associated with decreased rates of ever asthma (23.7% vs 33.7%; P < .005). CONCLUSIONS: Asthma, but not other manifestations of allergy, is less commonly reported among farm-reared children. Early exposures may be more important than those occurring later. Without ongoing exposures, their effects on disease expression may diminish over time.