Management of complicated acute sinusitis in the setting of concurrent COVID-19.

PURPOSE: Intraorbital and intracranial complications of acute bacterial rhinosinusitis require timely medical and surgical treatment to prevent the development of long-term neurologic sequelae. The era of Coronavirus Disease-2019 (COVID-19) has complicated the management of complicated acute rhinosinusitis, especially when patients have concurrent acute sinusitis and COVID-19 infection. This case series aims to highlight the clinical course of pediatric patients at a single tertiary pediatric hospital with concurrent complicated bacterial rhinosinusitis and COVID-19. MATERIALS AND METHODS: A search of pediatric patients treated for COVID-19 and complications from acute sinusitis was performed using billing records for the year 2020-2021 at a single pediatric tertiary hospital. Data regarding presentation, management, microbiology, and hospital course was collected for review. RESULTS: A total of 6 patients with complicated bacterial sinusitis in the setting of COVID-19 infection were included. All patients were initially managed with medical therapy, consisting of systemic antibiotics, but 3 of these patients ultimately required surgical intervention. Cultures from the cohort grew Staphylococcus aureus, streptococcus intermedius, streptococcus constellatus or Prevotella species. All patients experienced clinical improvements and were eventually discharged home with oral antibiotics. CONCLUSION: COVID-19 continues to be an unusual disease especially for the pediatric population. Concurrent complicated acute rhinosinusitis and COVID-19 appear to have higher rates of surgical requirement in the pediatric population. COVID-19 safety precautions have influenced management practices for patients with severe bacterial rhinologic infections. While there may be an association between complicated bacterial rhinosinusitis and COVID-19 infection, further research is necessary to determine a true correlation.

Use of Lean Healthcare to Improve Hospital Throughput and Reduce LOS.

Improving the discharge process is an area of focus throughout healthcare organizations. Capacity constraints, efficiency improvement, patient safety, and quality care are driving forces for many discharge process workgroups. METHODS: Following the Pareto principle, we focused on improving the discharge process on the medical-surgical units that received the most patients admitted from the emergency department. Increased demand for medical-surgical beds, renovations, and diminished bed capacity made it imperative to improve efficiency using quality improvement techniques. A core team of frontline staff decreased the time between computer entry of discharge orders and patient's departure from the unit to less than 60 minutes, with 80% compliance. The team developed a daily dashboard that detailed the process and outcome measures to create situational awareness and daily visual management. Additional observations of staff workflow uncovered excessive walking for printer use. Printers were placed at the point of use to reduce transport times. Next, using survey results provided by patients on discharge quality, a Treasure Map that aided with teach-back and Team Discharge were implemented to level the staff's workload. Finally, physicians discharged patients earlier in the day. They standardized their discharge criteria to remove subjectivity from the discharge process and enable better team involvement. RESULTS: After implementing 4 interventions, the average time between computer entry of discharge orders and patient's departure from the unit decreased (94.26 versus 65.98 minutes; P < 0.001), simultaneously reducing our average length of stay from 5.62 to 4.81 days (P < 0.001). CONCLUSIONS: In conclusion, hardwiring proven interventions and complementing them with daily visual management led to significant, sustained results.

Feasibility of a worksheet for facilitating self-management in children with asthma.

BACKGROUND: Few tools exist to facilitate recommended self-management support for children with asthma. We sought to examine the feasibility, acceptance and preliminary results of a novel worksheet designed to provide such support for children and their caregivers presenting for asthma care. METHODS: A 12-topic asthma worksheet was modeled on currently available self-management tools and based on the behavior change theory and motivational interviewing techniques. Children 1-18 years old with asthma and their caregivers were recruited from an allergy clinic and an inpatient ward to pilot test the worksheet by choosing three topics, generating self-management goals for each topic and assessing their self-efficacy for behavior change. Physician documentation of the visit was reviewed for comparison. Telephone follow up of self-management goals occurred 1 week after the visit. RESULTS: Forty-one of 46 eligible subjects agreed to participate (89%). Average completion time was 5:47 min (range 3:30-13:00). Most of them (98%) found the worksheet easy to understand, with minor modifications suggested. Topics most commonly selected were distinct from topics documented by physicians in the subsequent encounter (p < 0.01). Subjects generated 121 total self-management goals; 93% were at least "moderately confident" they could meet the goals. All 15 subjects reached by phone (37%) had achieved at least one goal at follow-up. CONCLUSIONS: A worksheet designed for self-management support of children is brief, feasible and acceptable in the clinical environment. This tool captures unique patient-centered preferences for behavior change, and shows promise for facilitating goal-setting and self-management education in the routine clinical care of pediatric asthma.

A Meta-analysis of the Rates of Listeria monocytogenes and Enterococcus in Febrile Infants.

CONTEXT: A change in the epidemiology of pathogens causing serious bacterial infection (SBI) has been noted since original recommendations were made for the empirical antibiotic choices for young infants with fever. OBJECTIVE: To assess the prevalence of SBI caused by Listeria monocytogenes and Enterococcus species. DATA SOURCES: A literature search was conducted on keywords related to SBI, L. monocytogenes, and Enterococcus spp. infections. STUDY SELECTION: Eligible studies were those conducted in the United States and published between January 1998 and June 2014 focusing on SBI in infants≤90 days of age. DATA EXTRACTION: The rates of urinary tract infection, bacteremia, and meningitis for each pathogen were recorded for each study. Meta-analysis was performed to calculate the prevalence for each pathogen in a random effects model with 0.5 continuity correction added to studies with zero events. RESULTS: Sixteen studies were included. A total of 20,703 blood cultures were included, with weighted prevalences for L. monocytogenes and Enterococcus spp. bacteremia of 0.03% and 0.09%, respectively. A total of 13,775 cerebrospinal fluid cultures were included with event rates (unweighted prevalences) for L. monocytogenes and Enterococcus spp. meningitis of 0.02% and 0.03%, respectively. A total of 18,283 urine cultures were included, with no cases of L. monocytogenes and a weighted prevalence for Enterococcus spp. urinary tract infection of 0.28%. LIMITATIONS: There may have been reporting bias or incomplete retrieval or inadvertent exclusion of relevant studies. CONCLUSIONS: SBI caused by L. monocytogenes and Enterococcus spp. in febrile infants is rare, and therefore clinicians may consider a change in empirical antibiotic choices.

Pain Prevalence and Treatment Patterns in a US Children's Hospital.

OBJECTIVE: Hospitalized children experience significant pain despite improvement efforts. This study was undertaken to better understand the epidemiology of acute pain in hospitalized children and the extent to which existing measures reveal targets for improving pain management. METHODS: A cross-sectional survey was used to audit pain assessment, intensity, prevalence, source, and treatment hospital-wide on a single day in 2011. Chart audits were performed on patients aged 0 to 21 years. All patients had the option to participate in a structured interview about their pain experience. RESULTS: The audit included 112 children, 47 of whom were interviewed. Pain prevalence obtained by child/parent interview (72%) was more than twice that documented by nurses (30%). Infants, but not cognitively impaired children, had significantly lower rates of pain detection and analgesic ordering than older age groups. Procedural pain was the most frequently cited source of pain among interviewed patients and was poorly addressed in the medical record. Fifty percent of children with documented moderate-to-severe pain received scheduled pain medications. More than one-third of interviewed patients would have wanted more pain medication if it could have been safely given. CONCLUSIONS: Specific gaps remain in the quality of pain management provided to hospitalized children. Focus on infant pain detection, assessment and management of procedural pain, and scheduled analgesic ordering are sensible targets for future process improvement efforts.

Impact of an evidence-based algorithm on quality of care in pediatric parapneumonic effusion and empyema.

OBJECTIVE: To determine whether implementation of a collaborative, evidence-based algorithm for care of pediatric parapneumonic effusion and empyema (PPE) can improve the quality of care delivered. STUDY DESIGN: Prospective cohort with retrospective control comparison of children aged 1 month to 18 years admitted with a clinical diagnosis of PPE. Quality improvement techniques were used to develop an algorithm, which was implemented September 2008. Primary outcome measures were decreased median and variability in length of stay (LOS), reduction in the use of chest computed tomography (CT), reduction in the total number of painful procedures, and increased initial use of effective drainage procedures when drainage was indicated. RESULTS: Compared with controls, algorithm implementation substantially reduced use of chest CT (0% vs. 41% of patients, P = 0.01) with no observed negative impact on LOS. Reductions in median LOS were not significant, but variability in LOS was reduced (P < 0.01 by F-test). Changes in number of procedures and use of effective drainage when indicated were in the predicted direction but not statistically significant. CONCLUSIONS: Quality improvement techniques are an effective means for incorporating evidence-based medicine into pediatric care. PPE can be managed safely without the use of chest CT.

Improving the quality of discharge communication with an educational intervention.

BACKGROUND: Communication between hospital providers and primary care physicians at the time of hospital discharge is necessary for optimal patient care and safety. Content of the inpatient discharge summary (DS) is not uniformly addressed by residency programs. OBJECTIVE: To improve DSs quality through a brief educational intervention. METHODS: We prospectively enrolled interns (first-year pediatric residents [PL1s]) in an educational intervention that consisted of a group session in which components of a high-quality DS were taught and a subsequent brief small-group session in which key components with distribution of a reminder card were reiterated. Six key components were identified: diagnosis; timely completion; pending laboratory work/studies; medications; length ≤3 pages; and discharge weight. DSs prepared by PL1s before and after the small-group session were objectively scored by blinded reviewers on the basis of how many DS components they contained (maximum score: 6). Scores were compared with historical controls of PL1s from the previous year. Audit scores were analyzed by using a mixed-effects linear regression model. RESULTS: Sixty-four PL1s were enrolled in the study; 477 DSs were scored. Mean score before the small-group reminder session was 3.6 in both groups. In mixed-effects models, scores in the intervention group increased by 0.56 points (P=.002) and DSs incorporating at least 5 of 6 components increased from 22% to 41% (P<.001) after the small-group session, whereas the control group's scores were unchanged. CONCLUSION: A brief, low-intensity educational intervention can improve quality of discharge communication and be incorporated into residency training. Electronic templates should incorporate prompts for key components of a DS.