Outcomes associated with initial narrow-spectrum versus broad-spectrum antibiotics in children hospitalized with urinary tract infections.

OBJECTIVE: The aim of this study is to describe the proportion of children hospitalized with urinary tract infections (UTIs) who receive initial narrow- versus broad-spectrum antibiotics across children's hospitals and explore whether the use of initial narrow-spectrum antibiotics is associated with different outcomes. DESIGN, SETTING AND PARTICIPANTS: We performed a retrospective cohort analysis of children aged 2 months to 17 years hospitalized with UTI (inclusive of pyelonephritis) using the Pediatric Health Information System (PHIS) database. MAIN OUTCOME AND MEASURES: We analyzed the proportions of children initially receiving narrow- versus broad-spectrum antibiotics; additionally, we compiled antibiogram data for common uropathogenic organisms from participating hospitals to compare with the observed antibiotic susceptibility patterns. We examined the association of antibiotic type with adjusted outcomes including length of stay (LOS), costs, and 7- and 30-day emergency department (ED) revisits and hospital readmissions. RESULTS: We identified 10,740 hospitalizations for UTI across 39 hospitals. Approximately 5% of encounters demonstrated initial narrow-spectrum antibiotics, with hospital-level narrow-spectrum use ranging from <1% to 25%. Approximately 80% of hospital antibiograms demonstrated >80% Escherichia coli susceptibility to cefazolin. In adjusted models, those who received initial narrow-spectrum antibiotics had shorter LOS (narrow-spectrum: 33.1 (95% confidence interval [CI]: 30.8-35.4) h versus broad-spectrum: 46.1 (95% CI: 44.1-48.2) h) and reduced costs [narrow-spectrum: $4570 ($3751-5568) versus broad-spectrum: $5699 ($5005-$6491)]. There were no differences in ED revisits or hospital readmissions. In summary, children's hospitals have low rates of narrow-spectrum antibiotic use for UTIs despite many reporting high rates of cefazolin-susceptible E. coli. These findings, coupled with the observed decreased LOS and costs among those receiving narrow-spectrum antibiotics, highlight potential antibiotic stewardship opportunities.

Changing patterns of routine laboratory testing over time at children's hospitals.

BACKGROUND: Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time. OBJECTIVES: To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes. DESIGN, SETTINGS, AND PARTICIPANTS: We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database. MAIN OUTCOMES AND MEASURES: We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A > 2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index. RESULTS: Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all ten years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.

Phlebotomy-free days in children hospitalized with common infections and their association with clinical outcomes.

BACKGROUND: Phlebotomy for hospitalized children has consequences (e.g., pain, iatrogenic anemia), and unnecessary testing is a modifiable source of waste in healthcare. Days without blood draws or phlebotomy-free days (PFDs) has the potential to serve as a hospital quality measure. OBJECTIVE: To describe: (1) the frequency of PFDs in children hospitalized with common infections and (2) the association of PFDs with clinical outcomes. DESIGN, SETTINGS AND PARTICIPANTS: We performed a cross-sectional study of children hospitalized 2018-2019 with common infections at 38 hospitals using the Pediatric Health Information System database. We included infectious All Patients Refined Diagnosis Related Groups with a median length of stay (LOS) >2 days. We excluded patients with medical complexity, interhospital transfers, those receiving intensive care, and in-hospital mortality. MAIN OUTCOME AND MEASURES: We defined PFDs as hospital days (midnight to midnight) without laboratory blood testing and measured the proportion of PFDs divided by total hospital LOS (PFD ratio) for each condition and hospital. Higher PFD ratios signify more days without phlebotomy. Hospitals were grouped into low, moderate, and high average PFD ratios. Adjusted outcomes (LOS, costs, and readmissions) were compared across groups. RESULTS: We identified 126,135 encounters. Bronchiolitis (0.78) and pneumonia (0.54) had the highest PFD ratios (most PFDs), while osteoarticular infections (0.28) and gastroenteritis (0.30) had the lowest PFD ratios. There were no differences in adjusted clinical outcomes across PFD ratio groups. Among children hospitalized with common infections, PFD ratios varied across conditions and hospitals, with no association with outcomes. Our data suggest overuse of phlebotomy and opportunities to improve the care of hospitalized children.

Variation in stool testing for children with acute gastrointestinal infections.

BACKGROUND AND OBJECTIVE: Children with gastrointestinal infections often require acute care.The objectives of this study were to describe variations in patterns of stool testing across children's hospitals and determine whether such variation was associated with utilization outcomes. DESIGN, SETTINGS AND PARTICIPANTS: We performed a multicenter, cross-sectional study using the Pediatric Health Information System (PHIS) database. We identified stool testing (multiplex polymerase chain reaction [PCR], stool culture, ova and parasite, Clostridioides difficile, and other individual stool bacterial or viral tests) in children diagnosed with acute gastrointestinal infections. MAIN OUTCOME AND MEASURES: We calculated the overall testing rates and hospital-level stool testing rates, stratified by setting (emergency department [ED]-only vs. hospitalized). We stratified individual hospitals into low, moderate, or high testing institutions. Generalized estimating equations were then used to examine the association of hospital testing groups and outcomes, specifically, length of stay (LOS), costs, and revisit rates. RESULTS: We identified 498,751 ED-only and 40,003 encounters for hospitalized children from 2016 to 2020. Compared to ED-only encounters, stool studies were obtained with increased frequency among encounters for hospitalized children (ED-only: 0.1%-2.3%; Hospitalized: 1.5%-13.8%, all p < 0.001). We observed substantial variation in stool testing rates across hospitals, particularly during encounters for hospitalized children (e.g., rates of multiplex PCRs ranged from 0% to 16.8% for ED-only and 0% to 65.0% for hospitalized). There were no statistically significant differences in outcomes among low, moderate, or high testing institutions in adjusted models. CONCLUSIONS: Children with acute gastrointestinal infections experience substantial variation in stool testing within and across hospitals, with no difference in utilization outcomes. These findings highlight the need for guidelines to address diagnostic stewardship.

Variation and Outcomes of Hospital-Level High-Flow Nasal Cannula Usage Outside of Intensive Care.

OBJECTIVES: Bronchiolitis is a viral respiratory infection that can progress to acute respiratory failure. This study evaluated the variability of hospital-wide high-flow nasal cannula (HFNC) usage outside of the ICU and its association with length of stay (LOS) and cost among pediatric patients admitted with bronchiolitis. METHODS: This study included patients <2 years old admitted with bronchiolitis between September 1, 2018 and March 31, 2019. Hospitals were divided into groups based on the proportion of patients among those who had never been in the ICU who received HFNC (non-ICU HFNC usage [NIHU]). We performed hierarchical mixed-model linear regression to estimate the association of NIHU with LOS and cost using multiplicative ratios (MR) and 95% confidence intervals (CI), both (1) unadjusted and (2) after adjusting for demographics, clinical characteristics, and individual utilization of HFNC and/or ICU. RESULTS: Unadjusted LOS was longer for patients in moderate (MR 1.14; 95% CI 1.11-1.18) and high (MR 1.26; 95% CI 1.22-1.30) NIHU hospitals. Adjusted LOS was longer in moderate (MR 1.03; 95% CI 1.01-1.06), and high (MR 1.08; 95% CI 1.05-1.11) NIHU hospitals. Unadjusted total cost was higher for patients in moderate (MR 1.20; 95% CI 1.16-1.25) and high (MR 1.26; 95% CI 1.22-1.31) NIHU hospitals. Adjusted total cost was higher for patients in moderate (MR 1.05; 95% CI 1.03-1.08), and high (MR 1.05; 95% CI 1.02-1.08) NIHU hospitals. CONCLUSIONS: In this study, increased NIHU is associated with increased LOS and total cost.

The increasing proportion of adult discharges at children's hospitals, 2004-2019.

Significant medical advances now enable individuals with pediatric illnesses to survive into adulthood. Finding medical homes for these individuals often remains challenging. We utilized the Pediatric Health Information System to measure the variation in and growth of admissions to children's hospitals, stratified by age and payor from 2004 to 2019. We identified 8,097,081 patient encounters from 30 hospitals. Compared to children, adults discharged at children's hospitals are more likely to have a complex chronic condition, have a higher median cost, and have a longer median length of stay. Hospital-level adult discharges ranged from 1.9% to 10.1% (median 4.1%; interquartile range: 2.8%-5.4%). Significantly higher increases were seen in each adult age subgroup (18-20, 21-25, and >25 years old) compared to the pediatric age group (p < .001). The number of adults discharged from children's hospitals is increasing faster than children, impacting children's hospitals and the populations they serve.

Variation in bacterial pneumonia diagnoses and outcomes among children hospitalized with lower respiratory tract infections.

BACKGROUND: Current diagnostics do not permit reliable differentiation of bacterial from viral causes of lower respiratory tract infection (LRTI), which may lead to over-treatment with antibiotics for possible bacterial community-acquired pneumonia (CAP). OBJECTIVES: We sought to describe variation in the diagnosis and treatment of bacterial CAP among children hospitalized with LRTIs and determine the association between CAP diagnosis and outcomes. DESIGN, SETTING AND PARTICIPANTS: This multicenter cross-sectional study included children hospitalized between 2017 and 2019 with LRTIs at 42 children's hospitals. MAIN OUTCOME AND METHODS: We calculated the proportion of children with LRTIs who were diagnosed with and treated for bacterial CAP. After adjusting for confounders, hospitals were grouped into high, moderate, and low CAP diagnosis groups. Multivariable regression was used to examine the association between high and low CAP diagnosis groups and outcomes. RESULTS: We identified 66,581 patients hospitalized with LRTIs and observed substantial variation across hospitals in the proportion diagnosed with and treated for bacterial CAP (median 27%, range 12%-42%). Compared with low CAP diagnosing hospitals, high diagnosing hospitals had higher rates of CAP-related revisits (0.6% [95% confidence interval: 0.5, 0.7] vs. 0.4% [0.4, 0.5], p = .04), chest radiographs (58% [53, 62] vs. 46% [41, 51], p = .02), and blood tests (43% [33, 53] vs. 26% [19, 35], p = .046). There were no significant differences in length of stay, all-cause revisits or readmissions, CAP-related readmissions, or costs. CONCLUSION: There was wide variation across hospitals in the proportion of children with LRTIs who were treated for bacterial CAP. The lack of meaningful differences in clinical outcomes among hospitals suggests that some institutions may over-diagnose and overtreat bacterial CAP.

Establishment of achievable benchmarks of care in the neurodiagnostic evaluation of simple febrile seizures.

BACKGROUND: Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures. OBJECTIVES: (1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care. OUTCOME MEASURES: Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs. RESULTS: We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization. CONCLUSIONS: Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.

Improving Sexually Transmitted Infection Screening in Inpatient Pediatric Patients.

BACKGROUND: Sexually transmitted infections (STIs) are a group of infectious diseases that cause acute illness and lifelong health effects. Half of the diagnosed cases occur in adolescents and young adults, ages 15 to 24. The American Academy of Pediatrics and the Centers for Disease Control and Prevention provide guidelines for STI screening for sexually active adolescents. Despite this, screening rates in adolescents admitted to our hospital are low. The purpose of this study is to use quality improvement methodology to improve the percent of adolescent patients who had documentation of sexual histories from 49% to 69% and STI testing from 29% to 49%. METHODS: Eligible patients included adolescents ages 14 to 18 admitted to our hospital's academic general pediatric service. After baseline data collection, we introduced a series of 6 interventions; percentages of sexual history documentation and STI screening were recorded monthly. Interventions included resident education on STI screening, history, and physical form prompts for sexual history documentation, "badge buddy" sexual history templates, faculty development, and an electronic medical record template. Data were interpreted by using statistical process control to show process change. RESULTS: Before the interventions, 48.7% of patients ages 14 to 18 had sexual histories documented; 29.1% of patients were tested for STIs. After interventions, there was a special cause variation resulting in new center lines of 67.1% and 49.1%, respectively. CONCLUSIONS: Simple interventions to normalize and standardize adolescent sexual history discussions cumulatively led to a significant increase in sexual history documentation and STI screening in an inpatient adolescent population.

Implementing a Standardized Clinical Pathway Leads to Reduced Asthma Admissions and Health Care Costs.

INTRODUCTION: Asthma exacerbations are 1 of the leading causes of hospital admissions in children in the United States. High volumes in the emergency department can lead to delayed treatment. Several studies have shown that implementation of a standardized clinical pathway can improve adherence to evidence-based standards. The purpose of our quality improvement project was to develop a standardized pathway of care for children with asthma exacerbations to improve time to treatment and reduce admissions. METHODS: The team used process mapping to review the current process of care for patients with asthma exacerbations presenting to the Emergency Department. After identification of several barriers, the team used plan-do-study-act cycles to develop a standardized clinical pathway of care for children based on their respiratory clinical score. Further interventions occurred after data collection and analyzation through run charts. RESULTS: Implementation of a standardized clinical pathway for children with asthma presenting to the Emergency Department resulted in treatment with steroids in less than 60 minutes. Overall admissions were decreased from an average of 24% to 17% throughout the intervention period. We estimated cost savings for the institution at over $230,000 for the 2 years after implementation of the pathway. CONCLUSIONS: Using a multidisciplinary team approach to develop a standardized clinical pathway for a common childhood illness like asthma can result in reduced time to treatment and admissions.

Decreasing Racemic Epinephrine for Bronchiolitis in an Academic Children's Hospital.

BACKGROUND AND OBJECTIVES: Bronchiolitis is a leading cause of pediatric hospitalizations in the United States. Although the American Academy of Pediatrics recommends against routine use of bronchodilators in bronchiolitis management, racemic epinephrine was persistently used for this purpose at Le Bonheur Children's Hospital. Our aim was to decrease racemic epinephrine use for bronchiolitis by 50% within 8 months. METHODS: Our multidisciplinary team used the Institute for Healthcare Improvement's Model for Improvement to develop an aim statement, choose metrics, and perform plan-do-study-act cycles to reduce racemic epinephrine use. We used focused education through in-person and online methods and provided direct feedback to residents, respiratory therapists, and nurses primarily caring for these children. The percentage of all patients admitted for bronchiolitis receiving at least 1 dose of racemic epinephrine was collected from the medical record and recorded on statistical process control charts for distribution to their work areas. Albuterol use and length of stay were collected as balancing measures. We used statistical process control charts to establish special cause variation and identify statistically significant differences in our measures. RESULTS: During our intervention period, the percentage of bronchiolitis patients receiving at least 1 dose of racemic epinephrine to treat bronchiolitis decreased from an average of 26% to 5%, and similarly, albuterol use decreased from an average of 48% to 34%. There was no clinically significant difference in length of stay. CONCLUSIONS: Using a multidisciplinary approach and focused education techniques may be an effective way to reduce racemic epinephrine use for children with bronchiolitis.